Galactogogues: medications that induce lactation

Effect of brewer's yeast or beta-glucan on breast milk supply following preterm birth: the BLOOM study - protocol for a multicentre randomised controlled trial

BACKGROUND

Many individuals who experience preterm birth struggle with early breast milk supply, which can translate into suboptimal longer-term breastfeeding outcomes. Further investigations into the potential role of early non-pharmacological and pharmacological interventions in improving breast milk production soon after birth is growing. While natural galactagogues, such as brewer's yeast, are widely perceived by women to be safer than pharmaceutical galactagogues and are taken by many women, evidence to support their efficacy is largely absent. The BLOOM study has been designed to determine the efficacy and safety of brewer's yeast and beta-glucans, derived from Saccharomyces cerevisiae, when administered soon after birth for increasing early breast milk supply in mothers who have delivered preterm.

METHODS

The BLOOM study is a multicentre, double-blinded, randomised controlled trial that will assess if brewer's yeast or beta-glucan can increase early breast milk production following preterm birth. Target population are mothers of preterm infants born at less than 34 weeks' gestation who intend to provide breast milk for their infant, are less than 72 h following birth and able to give informed consent. Participants will be randomly allocated into three parallel groups at 1:1:1 ratio (n = 33 per group) to receive either brewer's yeast, beta-glucan or placebo capsules for seven days. The primary outcome is total expressed breast milk volume over a 24-hour period on day 7 of intervention. Participants and their infants will be followed until the infant reaches term corrected age or is discharged home from the neonatal unit (whichever occurs first).

DISCUSSION

The use of brewer's yeast as a galactagogue to enhance milk production is extremely common amongst breastfeeding mothers, however, there are no trials evaluating its efficacy and safety. This will be the first randomised controlled trial to evaluate the efficacy and safety of two commonly used galactagogues, brewer's yeast and beta-glucan, compared with placebo in improving maternal breast milk supply following preterm birth. The trial will also evaluate whether early intervention with galactagogues soon after a preterm birth improves longer-term breastfeeding outcomes.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12622000968774 (registered on 8 July 2022) and UTN U1111-1278-8827.

Lactation induction in a transgender woman: case report and recommendations for clinical practice

BACKGROUND

We present a case of non-puerperal induced lactation in transgender woman. Medical literature on lactation induction for transgender women is scarce, and the majority of literature and protocols on lactation induction is based on research in cisgender women. Healthcare professionals may lack the precise knowledge about lactation induction and may therefore feel insecure when advice is requested. Subsequently, there is a rising demand for guidelines and support.

METHODS

Patient medical record was consulted and a semi-structured interview was conducted to explore the motive for lactation induction, the experience of lactation induction, and to gather additional information about the timeline and course of events.

CASE PRESENTATION

In this case a 37-year-old transgender woman, who was under the care of the centre of expertise on gender dysphoria in Amsterdam, and in 2020 started lactation induction because she had the wish to breastfeed her future infant. She was in a relationship with a cisgender woman and had been using gender affirming hormone therapy for 13 years. Prior to initiating gender affirming hormone therapy she had cryopreserved her semen. Her partner conceived through Intracytoplasmic Sperm Injection, using our patient's cryopreserved sperm. To induce lactation, we implemented a hormone-regimen to mimic pregnancy, using estradiol and progesterone, and a galactogogue; domperidone. Our patient started pumping during treatment. Dosage of progesterone and estradiol were significantly decreased approximately one month before childbirth to mimic delivery and pumping was increased. Our patient started lactating and although the production of milk was low, it was sufficient for supplementary feeding and a positive experience for our patient. Two weeks after birth, lactation induction was discontinued due to suckling problems of the infant and low milk production.

CONCLUSIONS

This case report underlined that lactation induction protocols commonly used for cisgender women are also effective in transgender women. However, the amount of milk produced may not be sufficient for exclusive nursing. Nevertheless, success of induced lactation may be attributed to its importance for parent-infant bonding, rather than the possibility of exclusive chestfeeding.

Early Breast Milk Volumes and Response to Galactogogue Treatment

The aim of this study was to evaluate the effect of galactogogue management in mothers of very preterm infants with varying breast milk volumes prior to initiating this treatment. Data were utilized from 90 women who participated in a trial employing domperidone. Three groups were formed according to their breast milk volumes (based on their infants’ birth weight) at the time of randomization and study entry to the trial protocol: (1) ≤100 mL/kg/d; (2) 101–200 mL/kg/d; and (3) ≥201 mL/kg/d. Breast milk volumes were evaluated at the 14- and 28-day study treatment periods. All three groups showed a significant volume increase and volume percent increase both at the 14-day measure and also the 28-day measure. Mothers who started in the two lower volume groups showed the greatest % volume change overall, with 356.2% in the ≤100 mL/kg/d and 106.1% in the 101–200 mL/kg/d groups, compared to those mothers in the higher group of ≥201 mL/kg/d, showing a change of 45.2%, where p = 0.001. Mothers producing varying low volumes were able to demonstrate an effect from the use of domperidone and increase their volumes as much as three-hundred-fold over 14- and 28-day study periods. However, those mothers whose volumes were ≤100 mL/kg/d continued to maintain low absolute milk volumes, putting these mothers at ongoing risk of ceasing lactation.

Investigation of the effect of metoclopramide on proliferation signal molecules in breast tissue

Metoclopramide (MCP) is a drug that has been widely used in recent years due to its hyperprolactinaemia effect on mothers during breastfeeding. The aim of this study was to investigate the proliferative changes that MCP may cause in the maternal breast tissue. In this study, 18 Wistar albino young-adult breastfeeding mothers with their offspring were divided into three groups: control group, low-dose MCP-applied group and high-dose MCP-applied group. The experiment was carried out during the lactation period and at the end of 21 days. Prolactin, BrdU and Ki-67 breast tissue distributions were evaluated by immunohistochemistry, and tissue levels were evaluated biochemically by the ELISA method. According to ELISA and immunohistochemistry results in breast tissue, there was no significant difference between Ki-67 and BrdU results in all groups. Metoclopramide did not change the expression of proliferation molecules Ki-67 and BrdU in breast tissue. These results suggested that while metoclopramide increases breast proliferation, it does not have the risk of transforming the tissue into a tumour.

Phytochemical screening and galactagogic attributes of Pergularia daemia (Forssk.) Chiov. leaf extract in lactating mice (Mus musculus)

Introduction

Pergularia daemia (Forssk.) Chiov. [PD] is used as a galactagogue by various tribes in Purulia district, India, lacks a scientific basis.

Objectives

The purpose of the study was to determine whether administration of aqueous leaf extract of P. daemia can increase milk production in lactating mice and encourages development in suckling pups.

Methods

30 lactating mice (n=6 per group) with a minimum of 5 pups each were treated with the aqueous PD extract at 50, 100, 150 and 200 mg/kg body weight while the control group was administered with only distilled water. The mice were daily fed with aqueous leaf extract via gavage, which started at day 3 and continued to day 15 post-partum and milk secretion was assessed by the weight-suckle-weight method. The qualitative estimation, UV-vis analysis and GC-MS study of the leaf extract was also done for the presence of phytoconstituents.

Results

Administration of aqueous leaf extract led to a considerable increase in milk production (28.1%) and the pups gained weight substantially (p<0.05) when compared to control. Milk production was enhanced in mice treated with 150 mg/kg b.wt. of leaf extract compared to other doses (p<0.05). The GC-MS analysis of the aqueous leaf extract of P. daemia revealed 20 major peaks, some with small retention time and also revealing presence of several phyto-estrogenic compounds.

Conclusion

The present study effectively demonstrated that aqueous leaf extract of PD enhanced milk production in mice and might be used as an alternative strategy for increasing milk production and can be extrapolated to farm animals and human beings.

Prevalence and the Determinants of Traditional, Complementary, and Integrative Medicine Use Among Breastfeeding Mothers: A Cross-Sectional Study

Objectives: Breastfeeding is highly important for a child's health, and the widespread use of herbal medicines as galactagogues has been reported. The present study was conducted to evaluate the use of traditional, complementary, and integrative medicine (TCIM) and its determinants among breastfeeding mothers in Shiraz, Iran. Design: Cross-sectional study. Setting/Location: Neonatal clinics affiliated to Shiraz University of Medical Sciences. Subjects: Mothers elder than 18 years old. Interventions: Nothing. Outcome Measures: Prevalence and of the use of TCIM products and its associated factors. Methods: In this cross-sectional study, mothers older than 18 years who referred to neonatal clinics affiliated to Shiraz University of Medical Sciences were enrolled. Using a structured interview, the authors explored the prevalence and of the use of TCIM products and its associated factors. Results: Of 625 mothers who were approached, 483 agreed to participate (response rate: 77.3%). The average age was 27.3 ± 5.9 years. The prevalence of using TCIM products during current breastfeeding was 97.1%. There were 168 working mothers (44.9%); 163 mothers (34.1%) complaining of postpartum breastfeeding problems, and 327 mothers (68%) had no history of breastfeeding. Recommendations of medical staff or relatives were the most frequent reasons for the consumption of TCIM products (64.9%). Only 27% of mothers disclosed the use of TCIM products to their doctor or health care provider, although 62% of mothers were asked about the use of such products. Notably, 438 mothers (95.8%) considered TCIM to increase their milk. Based on multivariable logistic regression, literacy and past use of TCIM galactagogues were independently associated with TCIM products use. Conclusions: The use of TCIM galactagogues is highly common among breastfeeding mothers in south of Iran, showing a diverse range of determinants. It is necessary to evaluate the safety and efficacy of common herbal galactagogues, and evidence-based studies must be designed to achieve standardized complementary medicine approaches in this regard.

Metoclopramide for Milk Production in Lactating Women: A Systematic Review and Meta-Analysis

Background

Breastfeeding is recognized as the optimal form of nutrition for the physical and neurological development of infants and is considered the most significant way to prevent child mortality. This study aimed to assess the effectiveness of metoclopramide for enhancing milk production in lactating women.

Methods

We searched the Cochrane Central Register of Controlled Trials and MEDLINE for randomized controlled trials comparing metoclopramide with a placebo, no treatment, or other galactagogue drugs. We included breastfeeding women with term or preterm infants.

Results

We retrieved 164 records from our search of the electronic databases and 20 records from other sources. Eight trials involving 342 lactating women that used metoclopramide were included in this review after assessing the eligibility criteria. The meta-analysis of these trials revealed that metoclopramide did not increase the milk volume of the intervention groups compared to that of the control groups. There was a significant increase in the serum concentrations of prolactin when the mothers were administered metoclopramide. No significant adverse events were reported.

Conclusion

Metoclopramide did not improve milk production in lactating women. Therefore, we do not recommend using metoclopramide to increase milk production in lactating women.

Comparison of ultrasound and microwave assisted extraction of diosgenin from Trigonella foenum graceum seed

From the recent market trend, there is a huge demand for the bioactive compounds from various food matrices that could be capable enough to combat the emerging health effects in day-to-day life. Fenugreek is a well-known spice from ancient times for its medicinal and health benefits. In the present study, two methods of green extraction microwave (MAE) and ultrasound (UAE) assisted were studied in regard of extraction of fenugreek diosgenin. In this study, solvent type (acetone, ethanol, hexane and petroleum ether), solvent concentration (40, 60, 80 and 100%) and treatment time (1.5, 3.0, 4.5 and 6.0 min and 30, 40, 50 and 60 min for MAE and UAE method respectively) was varied to observe the effect of these parameters over extract yield and diosgenin content. The results of this study revealed that treatment time, type of solvent and its concentration and method adopted for extraction of diosgenin has significant effect. In relation with better yield extract and diosgenin content, the yield of fenugreek seed extract was 7.83% with MAE and 21.48% with UAE of fenugreek seed powder at 80% ethanol concentration at 6 and 60 min respectively. The content of diosgenin was observed in fenugreek seed powder extract was 35.50 mg/100 g in MAE and 40.37 mg/100 g in UAE with 80% ethanol concentration at 6 and 60 min respectively. The overall range of yield of fenugreek extract was varied from 1.04% to 32.48% and diosgenin content was 15.82 mg/100 g to 40.37 mg/100 g of fenugreek seed powder including both extraction methods. This study revealed that UAE would impose better ways for preparing fenugreek extract and observing diosgenin content from fenugreek seeds.

Physico-Chemical Analysis and Fatty Acid Profiling of Fenugreek (Trigonella foenum-graecum) Seed Oil Using Different Solvents

Fenugreek (Trigonella foenum-graecum) a native to Southern Europe, Mediterranean region and Western Asia has been used as a spice all over the world to increase the sensory quality to the food. It is also known for its medicinal properties such as anti-diabetic, anti-carcinogenic, hypocholesterolemic and immunological activities and can also be used as a food stabilizer and emulsifying agent. The ash, protein, moisture and fiber content of defatted fenugreek seed powder obtained were 9%, 23.04%, 3.8%, 25.47% respectively. So, this study is systematically intended to determine the fatty acid composition, to be best among the different solvents used are the ethanol, petroleum ether, acetone and hexane for the extraction of the fenugreek seed oil and to analyze its susceptibility to oxidation. This study was carried out to investigate and examine the results such as acid value, peroxide value, saponification value, iodine value and the physical properties such as the color value and the refractive index of the seed oil. The results stipulate that the oil extracted using the solvent hexane had better quality and yield. Linoleic acid (41.97%) followed by alpha-linolenic acid (29.33%) and cis-9 oleic acid (12.95%) was found as the primary fatty acids present in the oil extracted using hexane. Along with these fatty acids, the PUFA content of hexane oil (71.30%) was also observed to be in a good range. So, on comparing these results with codex standards, it revealed that it can be considered as edible oil with further purifications.

Induced Lactation in a Mother Through Surrogacy With Complete Androgen Insensitivity Syndrome (CAIS)

INTRODUCTION

Breastfeeding offers the optimal feeding option for newborns in terms of nutritional content and reinforces mother-infant bonding. As a physiological process intrinsically linked to parturition, breastfeeding is no longer reserved for puerperal mothers. Progress in understanding the intricacies of lactogenesis and breastfeeding has further paved the way for artificially induced lactation in recent years.

MAIN ISSUES

We describe the case of a mother through surrogacy with XY karyotype and complete androgen insensitivity syndrome who wished to breastfeed her child.

MANAGEMENT

Through a combination of estrogen therapy, galactagogues, and mechanical breast stimulation she was able to partially breastfeed her child for one month.

CONCLUSION

This case further shifts the concept that breastfeeding is a physiological process confined to only puerperal mothers and offers an opportunity to a wider group of nontraditional mothers to take part in the unique experience of breastfeeding.

Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non-hospitalised term infants

BACKGROUND

Many women express concern about their ability to produce enough milk, and insufficient milk is frequently cited as the reason for supplementation and early termination of breastfeeding. When addressing this concern, it is important first to consider the influence of maternal and neonatal health, infant suck, proper latch, and feeding frequency on milk production, and that steps be taken to correct or compensate for any contributing issues. Oral galactagogues are substances that stimulate milk production. They may be pharmacological or non-pharmacological (natural). Natural galactagogues are usually botanical or other food agents. The choice between pharmacological or natural galactagogues is often influenced by familiarity and local customs. Evidence for the possible benefits and harms of galactagogues is important for making an informed decision on their use.

OBJECTIVES

To assess the effect of oral galactagogues for increasing milk production in non-hospitalised breastfeeding mother-term infant pairs.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Health Research and Development Network - Phillippines (HERDIN), Natural Products Alert (Napralert), the personal reference collection of author LM, and reference lists of retrieved studies (4 November 2019).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs (including published abstracts) comparing oral galactagogues with placebo, no treatment, or another oral galactagogue in mothers breastfeeding healthy term infants. We also included cluster-randomised trials but excluded cross-over trials.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. Two to four review authors independently selected the studies, assessed the risk of bias, extracted data for analysis and checked accuracy. Where necessary, we contacted the study authors for clarification.

MAIN RESULTS

Forty-one RCTs involving 3005 mothers and 3006 infants from at least 17 countries met the inclusion criteria. Studies were conducted either in hospitals immediately postpartum or in the community. There was considerable variation in mothers, particularly in parity and whether or not they had lactation insufficiency. Infants' ages at commencement of the studies ranged from newborn to 6 months. The overall certainty of evidence was low to very low because of high risk of biases (mainly due to lack of blinding), substantial clinical and statistical heterogeneity, and imprecision of measurements. Pharmacological galactagogues Nine studies compared a pharmacological galactagogue (domperidone, metoclopramide, sulpiride, thyrotropin-releasing hormone) with placebo or no treatment. The primary outcome of proportion of mothers who continued breastfeeding at 3, 4 and 6 months was not reported. Only one study (metoclopramide) reported on the outcome of infant weight, finding little or no difference (mean difference (MD) 23.0 grams, 95% confidence interval (CI) -47.71 to 93.71; 1 study, 20 participants; low-certainty evidence). Three studies (metoclopramide, domperidone, sulpiride) reported on milk volume, finding pharmacological galactagogues may increase milk volume (MD 63.82 mL, 95% CI 25.91 to 101.72; I² = 34%; 3 studies, 151 participants; low-certainty evidence). Subgroup analysis indicates there may be increased milk volume with each drug, but with varying CIs. There was limited reporting of adverse effects, none of which could be meta-analysed. Where reported, they were limited to minor complaints, such as tiredness, nausea, headache and dry mouth (very low-certainty evidence). No adverse effects were reported for infants. Natural galactagogues Twenty-seven studies compared natural oral galactagogues (banana flower, fennel, fenugreek, ginger, ixbut, levant cotton, moringa, palm dates, pork knuckle, shatavari, silymarin, torbangun leaves or other natural mixtures) with placebo or no treatment. One study (Mother's Milk Tea) reported breastfeeding rates at six months with a concluding statement of "no significant difference" (no data and no measure of significance provided, 60 participants, very low-certainty evidence). Three studies (fennel, fenugreek, moringa, mixed botanical tea) reported infant weight but could not be meta-analysed due to substantial clinical and statistical heterogeneity (I² = 60%, 275 participants, very low-certainty evidence). Subgroup analysis shows we are very uncertain whether fennel or fenugreek improves infant weight, whereas moringa and mixed botanical tea may increase infant weight compared to placebo. Thirteen studies (Bu Xue Sheng Ru, Chanbao, Cui Ru, banana flower, fenugreek, ginger, moringa, fenugreek, ginger and turmeric mix, ixbut, mixed botanical tea, Sheng Ru He Ji, silymarin, Xian Tong Ru, palm dates; 962 participants) reported on milk volume, but meta-analysis was not possible due to substantial heterogeneity (I² = 99%). The subgroup analysis for each intervention suggested either benefit or little or no difference (very low-certainty evidence). There was limited reporting of adverse effects, none of which could be meta-analysed. Where reported, they were limited to minor complaints such as mothers with urine that smelled like maple syrup and urticaria in infants (very low-certainty evidence). Galactagogue versus galactagogue Eight studies (Chanbao; Bue Xue Sheng Ru, domperidone, moringa, fenugreek, palm dates, torbangun, moloco, Mu Er Wu You, Kun Yuan Tong Ru) compared one oral galactagogue with another. We were unable to perform meta-analysis because there was only one small study for each match-up, so we do not know if one galactagogue is better than another for any outcome.

AUTHORS' CONCLUSIONS

Due to extremely limited, very low certainty evidence, we do not know whether galactagogues have any effect on proportion of mothers who continued breastfeeding at 3, 4 and 6 months. There is low-certainty evidence that pharmacological galactagogues may increase milk volume. There is some evidence from subgroup analyses that natural galactagogues may benefit infant weight and milk volume in mothers with healthy, term infants, but due to substantial heterogeneity of the studies, imprecision of measurements and incomplete reporting, we are very uncertain about the magnitude of the effect. We are also uncertain if one galactagogue performs better than another. With limited data on adverse effects, we are uncertain if there are any concerning adverse effects with any particular galactagogue; those reported were minor complaints. High-quality RCTs on the efficacy and safety of galactagogues are urgently needed. A set of core outcomes to standardise infant weight and milk volume measurement is also needed, as well as a strong basis for the dose and dosage form used.

Role of days postdelivery on breast milk production: a secondary analysis from the EMPOWER trial

Background

With an increasing demand for mother's own milk to be viewed as a primary source of nutritional support in the care of very small and preterm infants, mothers of preterm infants may be at risk of expressing suboptimal amounts of milk. The use of a galactogogue is often considered when these mothers are still having challenges in breast milk production.

Methods

For this analysis, the study participants were the 90 mothers who participated in the EMPOWER trial and, at the time of randomization, were stratified by days post-delivery, 8-14 days and 15-21 days. The primary outcome measure was the proportion of mothers in each of the days post-delivery groups who achieved a 50% increase in breast milk volume on day 14 of the study treatment period.

Results

There was no significant difference in the proportion of mothers in the 8-14 days group (75.0%) who achieved a 50% increase in breast milk volume on day 14 of the study treatment period.compared to those in the 15-21 days group (60.9%), OR 1.93 (95% CI 0.78, 4.76; p = 0.15). Because comorbidities and exposure to antenatal corticosteroids between the groups of mothers were viewed as potential confounders, a logistic regression was performed after controlling for these two variables with the adjusted OR being 1.84 (0.73, 4.64; p = 0.19).

Conclusions

This secondary analysis was able to demonstrate that mothers of very preterm infants, < 30 weeks gestation at birth, were able to respond to the study treatment in a similar fashion regardless of timing of entry and exposure to domperidone. In the presence of a suboptimal breast milk production by the end of the first week postpartum, below 250 ml/kg/d based on infant birth weight, a 14 day treatment of domperidone could be considered to augment breast milk production.

Trial registration

EMPOWER has been registered at http://www.clinicaltrials.gov (identifier NCT01512225) on January 10, 2012.

Effect of metoclopramide administration to mothers on neonatal bilirubin and maternal prolactin: a randomized, controlled, clinical trial

BACKGROUND

Jaundice is a common neonatal problem. This study was conducted to determine the effect of metoclopramide on neonatal bilirubin and maternal prolactin (primary outcomes) and milk volume (secondary outcome).

METHODS

This triple-blind, randomized, controlled, clinical trial was conducted on 112 mothers. The participants were assigned to the intervention (metoclopramide) and control groups (placebo) using block randomization. Ten-mg metoclopramide and placebo tablets were taken by the participants three times a day. The intervention began in the first 2-10 hours after childbirth and continued until the fifth day. The mothers' prolactin level was measured on the first morning after the intervention and on the sixth day (1 day after the intervention was over). Neonatal total bilirubin was also measured before the intervention and on the sixth day.

RESULTS

After the intervention, the two groups did not differ significantly in terms of the mean neonatal indirect bilirubin (P = 0.565) and milk volume (P = 0.261), but the mean serum prolactin was significantly higher in the metoclopramide group compared to the placebo group (adjusted mean difference 37; 95% confidence interval 58.1-16.5; P = 0.001).

CONCLUSIONS

Metoclopramide increased maternal serum prolactin but had no effects on neonatal jaundice. The insufficient numbers of studies on this subject mandate further research.

Prenatal developmental toxicity evaluation of Verbena officinalis during gestation period in female Sprague-Dawley rats

Verbena officinalis is widely used by women for maintaining general health and treating various gynaecological disorders during pregnancy. A case report has indicated that the consumption of V. officinalis induced an abortifacient effect. Hence, this study aimed to investigate the prenatal developmental toxicity of this plant according to OECD guideline (no. 414). A total of 50 pregnant female rats (dams) were distributed into five groups (n = 10); 500 mg/kg 1000 mg/2000 mg/kg and 3000 mg/kg of V. offcinalis extracts and the fifth group served as a normal control. All dams received their respective oral single daily treatment from the 6th to the 20th day of gestation. Maternal clinical toxicity signs, body weight and weight gain were recorded. Caesarean sections were performed on day 21 to evaluate embryo-foetal developmental toxicity. For dams, ovaries were harvested and weighed. The number of corpora lutea, implantation sites, and resorptions were recorded. No mortality was observed in dams, but their body weight gain was significantly reduced particularly in dams treated with 2000 and 3000 mg/kg V. officinalis. Asymmetrical distribution of implantation sites and embryos were observed. Embryo-fetotoxicity retardation was observed as evident by the decrease in foetal weight, head cranium, tail length, and higher incidence in the pre-and post-implantation loss. Some foetal skeleton abnormalities such as incomplete ossification of skull, sternebrae, and metatarsal bones were observed in foetuses of the 2000 and 3000 mg/kg V. officinalis-treated dams. LC/MS analysis identified the major constituents including geniposidic acid, tuberonic acid glucoside, luteolin 7, 3'-digalacturonide, iridotrial and apigenin. The glycosylated flavonoids such as apigenin and luteolin could be responsible for the reported prenatal developmental toxicity. In conclusion, the use of V. officinalis during pregnancy is not safe indicating evidence-based toxic effects on the reproductive performance of dams and dose-dependent risk potentials to the foetuses.

Effects of Fenugreek, Ginger, and Turmeric Supplementation on Human Milk Volume and Nutrient Content in Breastfeeding Mothers: A Randomized Double-Blind Controlled Trial

BACKGROUND

Exclusive breastfeeding is the best way to accomplish optimal growth and health in infants. Low milk volume is a major problem that leads to nonexclusive breastfeeding.

OBJECTIVE

This study aimed to examine the effects of mixed herbal supplementation, including fenugreek, ginger, and turmeric on human milk volume and nutrient content.

METHODS

The study design was a randomized double-blind controlled trial. Fifty exclusively breastfeeding mothers were randomly divided into two groups. The herbal group (n = 25) received mixed herbal supplementation containing fenugreek, ginger, and turmeric, three capsules three times daily for 4 weeks. The control group (n = 25) took a placebo. Anthropometric and dietary data, blood pressure, heart rate, and blood and milk samples were collected at baseline and 4 weeks after the intervention. Milk volume was measured using a manual breast pump and recorded for 2 days at baseline, week 2, and week 4.

RESULTS

Breastfeeding mothers receiving herbal supplementation had a 49% increase in milk volume at week 2 and a 103% increase at week 4. These increases were greater than mothers in the placebo group (p < 0.05). There was no difference in milk nutrient content for both groups. Moreover, there were no differences in adverse effects observed in the placebo and herbal groups.

CONCLUSION

Mixed herbal supplementation that contained fenugreek, ginger, and turmeric can increase human milk volume without adverse effects.

Pregnancy gestation at delivery and breast milk production: a secondary analysis from the EMPOWER trial

Background

Preterm birth alters the normal sequence of lactogenesis. Lactogenesis I may not yet have started when mothers of very preterm infants (≤ 29 weeks gestation) have given birth. Preterm infants are too small or too ill to initiate suckling in the immediate postpartum period thus altering the normal cascade of event for lactogenesis II. With an increasing demand for mother’s own milk as a primary source of nutritional support in the care of very small and preterm infants, mothers of these infants are often at risk of expressing inadequate amounts of milk. The use of galactogogues is often considered when mothers of preterm infants are still having challenges in breast milk production. What is not clear in the literature is the role that pregnancy gestation at birth plays in successful response to galactogogues. Our objective for this study was to evaluate the role of pregnancy gestation at birth on a mother’s response to the treatment interventions in the EMPOWER trial.

Methods

For this analysis, the study participants are the 90 mothers who participated in the EMPOWER trial and were in the stratified in two gestational age groups, 23^0/7–26^6/7 weeks and 27^0/7–29^6/7 weeks at the time of randomization. The primary outcome measures were the proportion of mothers in each of the gestational age groupings who achieved a 50% increase in breast milk volume on day 14 and day 28 of the study treatment period.

Results

On day 14 of the study treatment, there was no significant difference in the proportion of mothers in the 23–26 weeks gestation group (72.9%) compared to those in the 27–29 weeks gestation group (64.2%), OR 1.51 (95% CI 0.60, 3.78; p = 0.38). Similarly, there was no difference in the proportion of mothers between the two gestational age groupings on day 28 of the study treatment, 70.3% compared to 62.3%, OR 1.43 (95% CI 0.58, 3.51; p = 0.43).

Conclusion

This secondary analysis was able to demonstrate that mothers of very preterm infants, < 30 weeks gestation at birth, were able to respond to the study treatment in a similar fashion regardless of gestation at birth. If non-pharmacologic approaches are unsuccessful, then a 14–day treatment of domperidone may be considered to enhance breast milk production, even in the lowest gestational ages at delivery.

Trial registration

EMPOWER has been registered at www.clinicaltrials.gov (identifier NCT 01512225) on January 10, 2012.

Supporting Mothers of Very Preterm Infants and Breast Milk Production: A Review of the Role of Galactogogues

Human milk, either mother’s own milk or donor human milk, is recommended as the primary source of nutrition for very preterm infants. Initiatives should be in place in neonatal units to provide support to the mother as she strives to initiate and maintain a supply of breast milk for her infant. The use of galactogogues are considered when these initiatives alone may not be successful in supporting mothers in this endeavor. Although there are non-pharmacologic compounds, this review will focus on the pharmacologic galactogogues currently available and the literature related to their use in mothers of very preterm infants.

Which Benefits and Harms of Using Fenugreek as a Galactogogue Need to Be Discussed during Clinical Consultations? A Delphi Study among Breastfeeding Women, Gynecologists, Pediatricians, Family Physicians, Lactation Consultants, and Pharmacists

Background

Breastfeeding women with hypogalactia are commonly recommended to use fenugreek as a galactogogue. This study aimed to achieve formal consensus among breastfeeding women and healthcare providers on which potential harms and benefits of using fenugreek need to be communicated and discussed during clinical consultations.

Methods

A two-iterative round Delphi technique was used in two separate panels of breastfeeding women (n = 65) and healthcare providers (n = 56) to achieve formal consensus on a list of 24 and 16 items related to potential harms and benefits of fenugreek.

Results

About 70% of the healthcare providers recommended quite often herbal remedies for breastfeeding women and about 68% of the women had been recommended to use herbal remedies many times by their healthcare providers. Consensus was achieved on 21 potential harms and 14 potential benefits of using fenugreek to enhance human milk supply that need to be discussed with breastfeeding women during consultations.

Conclusion

Probably, potential harms and benefits of recommending fenugreek as herbal galactogogue for breastfeeding women seeking recommendations to increase their human milk supply need to be discussed during clinical consultations. Further observational studies are needed to assess what is being discussed in daily consultations when herbal remedies are recommended.

Effectiveness of fenugreek as a galactagogue: A network meta-analysis

A systematic review and network-meta analysis (NMA) were performed to test significance of the galactagogue effect of fenugreek administrated to lactating women versus other comparators (i.e., placebo/control/other galactagogues). A pairwise comparison for the treatment effect was carried out to generate the forest plot for the NMA. League tables were generated using treatment effect, weighted mean difference (WMD; 95% confidence interval, CI) for all pairwise comparisons, where WMD > 0 favors the column-defining treatment. Five studies were identified with 122 participants receiving treatment with fenugreek. The NMA results of 4 studies indicated that consumption of fenugreek significantly increased amount of the produced breast milk [11.11, CI 95% 6.77, 15.46] versus placebo. The pairwise comparison revealed that fenugreek was effective as a galactagogue compared to placebo, control, and reference groups WMD 17.79 [CI 11.71, 23.88]. However, the effect of fenugreek was substantially inferior to Coleus amboinicus Lour and palm date. The NMA using pairwise comparison demonstrated the effect of C. amboinicus and palm date in the stimulation of the breast milk production was comparable and superior to all comparators.

Management of Breast Milk Oversupply in Traditional Persian Medicine

Comprehensive explanation about milk oversupply is not available in the current literature because few studies have been done on this topic. In traditional Persian medicine, milk oversupply and its management have been described. The aim of this study was to investigate milk oversupply from the perspective of medieval Persian practitioners. In this study, some main medical resources of traditional Persian medicine such as Al-Havi and the Canon of Medicine were studied to extract valuable information about milk oversupply. Etiology of milk overproduction according to traditional Persian medicine is based on humors theory and cannot be easily compared with current medical concepts. Diet modifications and natural remedies have been applied for managing this condition but the majority of traditional Persian medicine interventions for reducing milk oversupply have not been scientifically investigated in modern medicine. The knowledge of milk oversupply in traditional Persian medicine may be helpful to conduct further related studies.

The Availability of Information on Induced Lactation in Malaysia

Induced lactation is a method of stimulating the production of breast milk in women who have not gone through the process of pregnancy. Recent advances in technology have given such women the opportunity to breastfeed adopted children. Previous studies conducted in Western countries have explored the breastfeeding of adopted children, as well as the experiences, successes and challenges of this process. However, research on procedures for breastfeeding adopted children is lacking in Malaysia. The authors have therefore reviewed literature related to induced lactation in Malaysia to fill this gap. Of the 30 related articles identified, 19 described the breastfeeding practices and experiences of adoptive mothers in Malaysia. Out of 19 articles, there were four journal articles, five circulars and regulations, two books, two post-graduate theses, four blogs posts and forum discussions, and two online newspaper articles. Medical information relating to induced lactation procedures was also reviewed, showing that there was a lack of scientific studies focusing on induced lactation practices among adoptive mothers. Information on religious, specifically Islamic, perspectives on breastfeeding and child adoption laws was gathered from websites, social networks, blogs, magazines and online news sources. In consideration of recent advancements in medical technology and the dire need among Malaysians, it is crucial that evidence-based, accurate and reliable information on induced lactation is made available to professionals and other individuals in this country.

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.

Enhancing Human Milk Production With Domperidone in Mothers of Preterm Infants

BACKGROUND

Mothers of preterm infants often are at risk of expressing an inadequate amount of milk for their infants and the use of galactogogues is often considered. Domperidone is a widely used galactogogue with little information available to guide clinicians regarding initiation, timing, and duration of treatment. Research aim: The primary objective of this study was to determine whether administration of domperidone within the first 21 days after delivery would lead to a higher proportion of mothers achieving a 50% increase in the volume of milk at the end of 14 days of treatment compared with mothers receiving placebo.

METHODS

Eligible mothers were randomized to one of two treatment arms: Group A-domperidone 10 mg orally three times daily for 28 days; or Group B-placebo 10 mg orally three times daily for 14 days followed by domperidone 10 mg orally three times daily for 14 days.

RESULTS

A total of 90 mothers of infants ≤ 29 weeks gestation were randomized. Mean milk volumes at entry were similar for both groups. More mothers achieved a 50% increase in milk volume after 14 days in Group A (77.8%) compared with Group B (57.8%), odds ratio = 2.56, 95% confidence interval [1.02, 6.25], p = .04.

CONCLUSION

A greater number of mothers experienced a 50% or more increase in human milk volume, but the absolute increase in milk volume was modest.

Botanicals and Their Bioactive Phytochemicals for Women's Health

Botanical dietary supplements are increasingly popular for women's health, particularly for older women. The specific botanicals women take vary as a function of age. Younger women will use botanicals for urinary tract infections, especially Vaccinium macrocarpon (cranberry), where there is evidence for efficacy. Botanical dietary supplements for premenstrual syndrome (PMS) are less commonly used, and rigorous clinical trials have not been done. Some examples include Vitex agnus-castus (chasteberry), Angelica sinensis (dong quai), Viburnum opulus/prunifolium (cramp bark and black haw), and Zingiber officinale (ginger). Pregnant women have also used ginger for relief from nausea. Natural galactagogues for lactating women include Trigonella foenum-graecum (fenugreek) and Silybum marianum (milk thistle); however, rigorous safety and efficacy studies are lacking. Older women suffering menopausal symptoms are increasingly likely to use botanicals, especially since the Women's Health Initiative showed an increased risk for breast cancer associated with traditional hormone therapy. Serotonergic mechanisms similar to antidepressants have been proposed for Actaea/Cimicifuga racemosa (black cohosh) and Valeriana officinalis (valerian). Plant extracts with estrogenic activities for menopausal symptom relief include Glycine max (soy), Trifolium pratense (red clover), Pueraria lobata (kudzu), Humulus lupulus (hops), Glycyrrhiza species (licorice), Rheum rhaponticum (rhubarb), Vitex agnus-castus (chasteberry), Linum usitatissimum (flaxseed), Epimedium species (herba Epimedii, horny goat weed), and Medicago sativa (alfalfa). Some of the estrogenic botanicals have also been shown to have protective effects against osteoporosis. Several of these botanicals could have additional breast cancer preventive effects linked to hormonal, chemical, inflammatory, and/or epigenetic pathways. Finally, although botanicals are perceived as natural safe remedies, it is important for women and their healthcare providers to realize that they have not been rigorously tested for potential toxic effects and/or drug/botanical interactions. Understanding the mechanism of action of these supplements used for women's health will ultimately lead to standardized botanical products with higher efficacy, safety, and chemopreventive properties.

Domperidone for Treatment of Low Milk Supply in Breast Pump-Dependent Mothers of Hospitalized Premature Infants: A Clinical Protocol

Mothers of hospitalized premature infants who choose to provide breast milk are at increased risk of an inadequate breast milk supply. When nonpharmacologic interventions to increase milk supply fail, clinicians are faced with limited options. There is no current evidence to support the use of herbal galactogogues in this population and a black box warning for metoclopramide for potential serious side effects. Thus, domperidone was the only known, effective option for treatment of low milk supply in this population. With a thorough review of the literature on domperidone and coordination with the obstetrical, neonatal, lactation, and pharmacology teams, a domperidone treatment protocol for mothers of hospitalized premature infants with insufficient milk supply was developed at our institution and is presented in this article. A comprehensive understanding of domperidone for use as a galactogogue with a standard treatment protocol will facilitate safer prescribing practices and minimize potential adverse reactions in mothers and their hospitalized premature infants.

Dietary fenugreek seed extract improves performance and reduces fecal E. coli counts and fecal gas emission in lactating sows and suckling piglets

Hossain, M. M., Begum, M., Nyachoti, C. M., Hancock, J. D. and Kim, I. H. 2015. Dietary fenugreek seed extract improves performance and reduces fecal E. coli counts and fecal gas emission in lactating sows and suckling piglets. Can. J. Anim. Sci. 95: 561–568. This study evaluated the efficacy of fenugreek seed extract (FSE) in sows and suckling piglets. The trial was conducted with 78 multiparous sows and their litters in a 28-d feeding trial, and one of three diets: CON (control, basal diet); FSE1 (basal diet+0.1% FSE), and FSE2 (basal diet+0.2% FSE). Piglets suckling sows fed the FSE1 and FSE2 diets had higher average daily gain compared with those suckling sows fed the CON from week 2 to weaning (linear, P<0.05). At weaning, sows fed the FSE1 and FSE2 diets had higher immunoglobulin G and lower low-density lipoprotein–cholesterol concentrations compared with those fed the CON diet (linear, P<0.05). Sows fed the FSE2 diet linearly reduced total cholesterol concentrations at weaning (P<0.05). Piglets suckling sows fed the FSE2 diet had higher immunoglobulin G and red blood cell concentrations compared with those suckling sows fed the CON diet (linear, P<0.05). Sows fed the FSE2 diet had higher apparent total tract digestibility of N and gross energy and reduced fecal E. coli counts and ammonia gas emission compared with those fed the CON diet at weaning (linear, P<0.05). In conclusion, results indicate that feeding sows a diet supplemented with FSE in late gestation and lactation improved performance in sows and suckling piglets.

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.

The Effect of Herbal Tea Containing Fenugreek Seed on the Signs of Breast Milk Sufficiency in Iranian Girl Infants

BACKGROUND

One of the important reasons behind termination of breast-feeding in the first six months after childbirth is insufficient production of breast milk.

OBJECTIVES

The aim of this study was to determine the effect of herbal tea containing fenugreek seed on the signs of breast milk sufficiency in Iranian girl infants aged 0 - 4 months, at the medical health centers of Tehran university of medical sciences.

PATIENTS AND METHODS

This study was a clinical trial with a control group. Seventy-eight girl infants, 0 - 4 months old that were exclusively breastfed by their mothers, were randomly assigned to the intervention group (received herbal tea containing 7.5 g fenugreek seed powder in addition to 3 g of black tea, three times a day) and the control group (received herbal tea containing 3 g of black tea powder, three times a day). Before and during the four weeks of study, the signs of breast milk sufficiency were evaluated through measurement of growth parameters and use of follow-up forms for measuring the number of wet diapers in one day, frequency of defecation and infant breast-feeding times in a day.

RESULTS

Before the intervention there was no significant difference between weight, height, head circumference, the number of wet diapers and frequency of defecation between the two groups (P > 0.05), yet the number of breast feeding times of the control group was more than the Fenugreek group. At the end of the fourth week in proportion to the pre-intervention conditions, the weight of the infants in the fenugreek group increased significantly from 5282.0513 ± 1021.51121 to 6383.0769 ± 952.06190, while head circumference increased from 38.3103 ± 1.62736 to 39.9256 ± 1.50660, number of wet diapers from 5.2821 ± 0.93044 to 8.1648 ± 1.20620, frequency of defecation from 1.8846 ± 1.08495 to 2.7326 ± 0.94771 and the number of breast feeding times from 9.1795 ± 1.39778 to 15.9597 ± 1.45056 (P < 0.001). However, there was no significant effect on height variation (P = 0.078). While in the control group there was no significant difference between the mentioned variables (P > 0.05).

CONCLUSIONS

Herbal tea of fenugreek seed in comparison to the control group improves the signs of breast milk sufficiency.

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.

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.

The effect of two different domperidone doses on maternal milk production

BACKGROUND

The benefits of breast milk to the newborn infant are well established. The Canadian Paediatric Society recommends exclusive breastfeeding for the first 6 months of life for healthy, term infants. Mothers of premature newborns, however, may have difficulty providing an adequate supply of breast milk. Domperidone is officially used as a prokinetic agent. However, it is used widely around the world as a galactogogue. Despite its widespread use as a galactogogue, only a small number of investigators have studied domperidone for this indication.

AIMS

The purpose of this study was to determine an optimal dosage of domperidone as a galactogogue.

METHODS

Eligible subjects were randomized to receive domperidone 10 mg 3 times daily or domperidone 20 mg 3 times daily for 4 weeks. At week 5, the frequency was decreased to twice daily in both groups, and finally once daily for week 6.

RESULTS

Over the entire first 4-week period, there was a significant increase in daily milk volumes within each group (P < .01). The between-group difference over this period, although not statistically significant, was clinically significant. Additionally, there was no significant within- or between-group difference during weeks 5 and 6.

CONCLUSION

A dose of domperidone of 20 mg, 3 times daily instead of 10 mg, 3 times daily was associated with a clinical, but not statistically significant, increase in milk production.

The effect of galactagogue herbal tea on oxidant and anti-oxidant status of human milk

OBJECTIVE

Human milk (HM) has antioxidant constituents which protect newborns against oxidative damage. We aimed to evaluate whether maternal consumption of herbal tea containing fenugreek had any effects on global oxidant and antioxidant capacity of HM.

METHODS

Volunteer mothers 18-35 years of age without any antenatal or perinatal risk factors were randomly assigned to receive galactagogue herbal tea (Humana still-tee®, Herford, Deutschland) 3 cups/d or same amount of water as placebo. The total antioxidant capacity (TAC), total oxidant status (TOS) and the oxidative stress index (OSI) of breast milk samples taken in the 1st day and 7-10 d were compared between groups.

RESULTS

Herbal tea (n = 40) and placebo (n = 40) groups had similar TAC, TOS and OSI values in the 1st day samples. TAC, TOS and OSI values in the breast milk samples taken on 7-10th day were also similar. OSI increased significantly in 7-10 day samples compared to 1st day in each group, while TAC and TOS levels did not differ.

CONCLUSION

Galactagogue herbal tea containing fenugreek has no detectable effect on global oxidant and antioxidant status of HM. OSI increases in course of lactation compared to colostrums irrespective of galactagogue use.

Human milk for the premature infant

Premature infants are at risk for growth failure, developmental delays, necrotizing enterocolitis, and late-onset sepsis. Human milk from women delivering prematurely has more protein and higher levels of bioactive molecules. Human milk must be fortified for premature infants to achieve adequate growth. Mother's own milk improves growth and neurodevelopment, decreases the risk of necrotizing enterocolitis and late-onset sepsis, and should be the primary enteral diet for premature infants. Donor milk is a resource for premature infants whose mothers are unable to provide an adequate supply of milk. Challenges include the need for pasteurization, nutritional and biochemical deficiencies, and limited supply.

Audit of domperidone use as a galactogogue at an Australian tertiary teaching hospital

BACKGROUND

Domperidone is often used to promote lactation among women who have difficulty breastfeeding.

OBJECTIVE

To examine prescribing and dispensing practices of domperidone at the Women's and Children's Hospital (WCH), Adelaide.

METHODS

A retrospective audit of domperidone dispensing among women with singleton pregnancies who delivered at the WCH between January 2000 and July 2010 was undertaken. Women dispensed domperidone were identified using WCH pharmacy dispensing records. Maternal and infant clinical data were obtained from the WCH Perinatal Statistics Collection. An audit of paper-based medical records was undertaken for a random sample of 261 mother-child pairs to collect prescribing and additional clinical data.

RESULTS

From 2000 to 2010, 1605 women were dispensed domperidone. There was a steady increase in the percentage of women dispensed domperidone, from < 0.5% in 2000 to > 5% of total WCH pregnancies in 2010. Among women dispensed domperidone, the percentage of women who received > 1 dispensing remained consistent (20%) over time, as did the median number of days (12) from delivery to first dispensing. Multiparous women were more likely to receive domperidone within 3 days following delivery compared to primiparous women (8% vs 4%; P < .01). Most women (80%) received directions to take domperidone according to a standard tapering dosing regimen over 12 days. Notably, 60% of women had no documentation of being assessed by a lactation consultant.

CONCLUSION

From 2000 to 2010, there was a considerable increase in domperidone dispensing. With a lack of clinical evidence to guide use, current practice appears to be based on anecdotal evidence.

The use of galactogogues in the breastfeeding mother

OBJECTIVE

To review data regarding the efficacy of galactogogues available in the US to increase breast milk production in postpartum mothers.

DATA SOURCES

Literature was sought using PubMed (1966-June 2012) and EMBASE (1973-June 2012). Search terms included breastfeeding, breast milk, lactation, galactogogue, metoclopramide, oxytocin, fenugreek, milk thistle, silymarin, growth hormone, thyroid releasing hormone, medroxyprogesterone, domperidone, goat's rue, beer, Asparagus racemosus, shatavari, Medicago sativa, alfalfa, Onicus benedictus, blessed thistle, Galega officinalis, brewer's yeast, and herbals.

STUDY SELECTION AND DATA EXTRACTION

All studies including humans and published in English with data assessing the efficacy of galactogogues for increasing breast milk production were evaluated.

DATA SYNTHESIS

Breast milk is considered the optimal food source for newborns through 1 year of age. Many factors influence overall maternal production, including maternal pain, illness, balance of time when returning to work, anxiety, or emotional stress. Although a variety of herbal and pharmaceutical options have anecdotal evidence of their ability to improve breast milk production, peer-reviewed studies proving their efficacy are lacking. Metoclopramide, oxytocin, fenugreek, and milk thistle have shown mixed results in improving milk production; however, the trials were small and had a variety of limitations.

CONCLUSIONS

Nonpharmacologic recommendations should be exhausted before adding therapy. Although anecdotal evidence encourages the use of metoclopramide, fenugreek, asparagus, and milk thistle for their galactogogue properties, efficacy and safety data in the literature are lacking. Oxytocin and domperidone are potentially available for compounding purposes, but safety data are limited. More studies are needed to evaluate the effects of available galactogogues on breast milk production.

Enhancing breast milk production with Domperidone in mothers of preterm neonates (EMPOWER trial)

Background

The use of mother’s own breast milk during initial hospitalization has a positive impact not only in reducing potential serious neonatal morbidities but also contribute to improvements in neurodevelopmental outcomes. Mothers of very preterm infants struggle to maintain a supply of breast milk during their infants’ prolonged hospitalization. Galactogogues are medications that induce lactation by exerting its effects through oxytocin or prolactin enhancement. Domperidone is a potent dopamine D₂ receptor antagonist which stimulates the release of prolactin. Small trials have established its ability in enhancing breast milk production. EMPOWER was designed to determine the safety and efficacy of domperidone in mothers experiencing an inadequate milk supply.

Methods/design

EMPOWER is a multicenter, double masked, randomized controlled phase-II trial to evaluate the safety and effectiveness of domperidone in those mothers identified as having difficulty in breast milk production. Eligible mothers will be randomized to one of two allocated groups: Group A: domperidone 10 mg orally three times daily for 28 days; and Group B: identical placebo 10 mg orally three times daily for 14 days followed by domperidone 10 mg orally three times daily for 14 days. The primary outcome will be determined at the completion of the first 2-week period; the second 2-week period will facilitate answering the secondary questions regarding timing and duration of treatment. To detect an estimated 30% change between the two groups (from 40% to 28%, corresponding to an odds ratio of 0.6), a total sample size of 488 mothers would be required at 80% power and alpha = 0.05. To account for a 15% dropout, this number is increased to 560 (280 per group). The duration of the trial is expected to be 36–40 months.

Discussion

The use of a galactogogue often becomes the measure of choice for mothers in the presence of insufficient breast milk production, particularly when the other techniques are unsuccessful. EMPOWER is designed to provide valuable information in guiding the practices for this high-risk group of infants and mothers. The results of this trial will also inform both mothers and clinicians about the choices available to increase and maintain sufficient breast milk.

Trial registration

Clinical Trials.gov Identifier: NCT01512225

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.

Lactogenic activity of rats stimulated by Gunnera perpensa L. (Gunneraceae) from South Africa

Gunnera perpensa L. (Gunneraceae) is a medicinal plant used by Zulu traditional healers to stimulate milk production. The effect of an aqueous extract of the rhizome of the plant on milk production in rats was investigated. Female lactating rats that received oral doses of the extract of G.perpensa significantly (p<0.05) produced more milk than controls. The plant extract did not however, significantly influence the levels of prolactin, growth hormone, progesterone, cortisol, ALT, AST and albumin in the blood. The mammary glands of rats treated with the extract showed lobuloalveolar development. The extract (0.8 µg/ml) was also found to stimulate the contraction of the uterus and inhibit (23%) acetylcholinesterase activity. The cytotoxicity of the extract (LC₅₀) to two human cell lines (HEK293 and HepG2) was 279.43 µg/ml and 222.33µg/ml, respectively. It is inferred that the plant extract exerts its activity on milk production and secretion by stimulating lobuloalveolar cell development and the contraction of myoepithelial cells in the alveoli. It is concluded that Gunnera perpensa contains constituents with lactogenic activity that apparently contribute to its effectiveness in folk medicine.