What Evidence Do We Have for Pharmaceutical Galactagogues in the Treatment of Lactation Insufficiency?-A Narrative Review

Efficacy and safety of domperidone and metoclopramide on human milk production in postpartum mothers: a bayesian network meta-analysis of randomized controlled trials

BACKGROUND

Breastfeeding is the most advantageous nutrition for infants because of its many health benefits. However, lactation insufficiency is a prevalent issue among women, particularly those who give birth prematurely. Galactagogues, such as domperidone and metoclopramide, have been reported and may be beneficial for lactation insufficiency. However, the optimal pharmacological galactagogue remains unclear.

METHODS

The PubMed, MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library databases were searched from their inception to April 23, 2023. The primary aim of this research was to assess the efficacy and safety of domperidone and metoclopramide using Bayesian network meta-analysis. The efficacy outcome was the increased breast milk volume (in mL/day). The safety outcome was the frequency of maternal drug-related adverse events during the study period.

RESULTS

Seventeen randomized controlled trials were included in the final analyses. Preterm mothers who took domperidone had a greater increase in breast milk volume than those who took metoclopramide or placebo (domperidone vs. metoclopramide: MD = 82.84, 95% CI: 37.04-118.95; domperidone vs. placebo: MD = 88.30, 95% CI: 59.48-118.62). However, in the term mothers, domperidone did not show the above benefit compared with metoclopramide or placebo (domperidone vs. metoclopramide: MD = 93.67, 95% CI: -186.11-375.59; domperidone vs. placebo: MD = 126.25, 95% CI: -49.91-304.55). Both in preterm and term mothers, metoclopramide was no better than the placebo. There was no difference in the frequency of maternal drug-related adverse outcomes among domperidone, metoclopramide, and placebo.

CONCLUSION

Domperidone increased the daily breast milk volume in mothers of preterm infants, without serious adverse events. However, this conclusion is limited due to the small sample sizes in the studies analyzed.

Increased Cardiometabolic Risk in Men with Hypoprolactinemia: A Pilot Study

Low prolactin levels in men predispose them to mood disturbances, sexual dysfunction, and diabetes. The purpose of the current study was to assess cardiometabolic risk in males with hypoprolactinemia. This prospective study included three age-matched groups of young and middle-aged men: individuals with cabergoline-induced hypoprolactinemia (n = 15), cabergoline-treated subjects with prolactin levels within the reference range (n = 20), and untreated men with normal prolactin levels (n = 31). In men with hypoprolactinemia, the cabergoline dose was reduced in order to normalize prolactin concentration. Anthropometric parameters, blood pressure, QRISK3 score; plasma concentrations of prolactin, glucose, insulin, lipids, uric acid, high-sensitivity C-reactive protein (hsCRP), fibrinogen, homocysteine, and testosterone; whole-blood levels of glycated hemoglobin (HbA1C); urinary albumin-to-creatinine ratio (UACR); and carotid intima-media thickness were assessed at baseline and six months later. Men with hypoprolactinemia were characterized by higher body mass index, fat content, waist circumference, systolic blood pressure, fasting and 2 h post-load glucose, HbA1C, HOMA1-IR, uric acid, hsCRP, fibrinogen, homocysteine, and UACR; by lower HDL cholesterol and testosterone; by greater intima-media thickness; and by a higher QRISK3 score than their peers with normal prolactin levels. There were no statistically significant differences in the measured parameters between both groups of men with normal prolactin levels. Normalization of prolactin concentration was accompanied by normalization of biochemical variables, systolic blood pressure, and QRISK3 score. Although cabergoline dose reduction did not cause statistically significant changes in the remaining anthropometric parameters and intima-media thickness, six months later, they did not differ from those observed in the remaining study groups. Our findings suggest that iatrogenic hypoprolactinemia is associated with increased cardiometabolic risk, which is reversible and resolves after the normalization of prolactin levels.

The Aqueous Extract of Hemerocallis citrina Baroni Improves the Lactation-Promoting Effect in Bovine Mammary Epithelial Cells through the PI3K-AKT Signaling Pathway

Insufficient milk supply is a widespread issue faced by women globally and associated with a higher risk of health problems in infants and mothers. Hemerocallis citrina Baron, commonly known as daylily, is a perennial edible plant often used in traditional Asian cuisine to promote lactation. However, the active compound(s) and mechanism of its lactation-promoting effect remain unclear. This study aimed to confirm the traditional use of daylily in promoting lactation and investigate its potential active components and underlying molecular mechanisms. Our results showed that the aqueous extracts of H. citrina Baroni (HAE) significantly enhanced milk production, and the serum levels of lactation-related hormones, and promoted mammary gland development in lactating rats, as well as increased the levels of milk components in bovine mammary epithelial cells (BMECs) (p < 0.05). UHPLC-Q-Exactive Orbitrap-MS analysis revealed that hexamethylquercetin (HQ) is the representative flavonoid component in HAE, accounting for 42.66% of the total flavonoids. An integrated network pharmacology and molecular docking analysis suggested that HQ may be the potential active flavonoid in HAE that promotes lactation, possibly supporting lactation by binding to key target proteins such as STAT5A, PIK3CA, IGF1R, TP53, CCND1, BCL2, INS, AR, and DLD. Cell experiments further demonstrated that HQ could promote cell proliferation and the synthesis of milk proteins, lactose, and milk fat in BMECs. Transcriptomic analysis combined with a quantitative reverse transcription polymerase chain reaction (RT-qPCR) revealed that both HAE and HQ exert a lactation-promoting function mainly through regulating the expression of key genes in the PI3K-Akt signaling pathway.

Physiology of Human Lactation and Strategies to Support Milk Supply for Breastfeeding

Despite advances across the globe in breastfeeding initiation rates, many families continue to report they are not meeting their breastfeeding goals. Concerns about milk supply, infant nutritional intake, and infant weight gain are among the most commonly cited reasons for early breastfeeding cessation. Nurses working with individuals during the perinatal period are uniquely positioned to educate families and offer evidence-based interventions to promote optimal milk supply, infant growth, and maternal mental and physical health. Such interventions include early and frequent skin-to-skin care, emptying of the breast, and professional lactation support. By implementing such evidence-based practices in the first hours after birth and connecting families to lactation support in the first 14 days, nurses can begin to help families achieve their breastfeeding goals.

Efficacy and safety of acupuncture for postpartum hypogalactia: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Postpartum hypogalactia (PH) is prominent during lactation and may negatively impact the mother's or infant's health. Acupuncture is widely used to increase maternal breast milk production. However, the effects of acupuncture on PH remain unclear. Therefore, this review aimed to evaluate the efficacy and safety of acupuncture in individuals with PH.

MATERIALS AND METHODS

Articles on potentially eligible randomized controlled trials (RCTs) on acupuncture for PH published from database inception to October 2023 were retrieved from the PubMed, Web of Science, Cochrane Library, EMBASE, EBSCO, Scopus, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, WanFang, and VIP databases. Two reviewers independently screened the records, extracted essential information, and evaluated the methodological quality of the RCTs using the revised Cochrane risk-of-bias (RoB) tool. The primary outcome was a change in serum prolactin (PRL) levels before and after treatment. Secondary outcomes included milk secretion volume (MSV), total effective rate (TER), mammary fullness degree (MFD), and exclusive breastfeeding rate (EBR). Meta-analyses were performed using RevMan v5.4. Finally, the quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation tool.

RESULTS

This study included 19 RCTs involving 2,400 participants. The included studies were classified as having an unclear to high RoB. Our findings indicated that, overall, acupuncture showed a significant effect in increasing serum PRL levels (standardized mean differences [SMDs] = 1.09, 95% confidence interval [CI]: 0.50, 1.68), MSV (SMD = 1.69, 95% CI: 0.53, 2.86), TER (relative risk [RR] = 1.25, 95% CI: 1.10, 1.42), and EBR (RR = 2.01, 95% CI: 1.07, 3.78) compared to that in the control group; however, no difference in MFD (SMD = 1.17, 95% CI: -0.09, 2.42) was observed. In the subgroup analysis, acupuncture combined with Chinese herbs or conventional treatment was significantly more effective in increasing serum PRL levels, MSV, and TER than did Chinese herbs or conventional treatment alone. Moreover, acupuncture alone resulted in significantly higher serum PRL levels compared to Chinese herbs; however, this benefit was not observed for TER and MFD. The quality of evidence was critically low.

CONCLUSION

Acupuncture may effectively increase milk secretion in women with PH. However, owing to the low quality of evidence, further rigorously designed studies are warranted to confirm our findings.

No Measurable Transfer of Oxytocin-Receptor Agonist Merotocin Detected in Human Breast Milk

Objective: The study aimed to assess the transfer of merotocin from systemic circulation to breast milk in early postpartum women and women with established lactation. Methods: This was a two-part, multicenter, open-label, parallel-group study. Merotocin was administered as a single 90-minute intravenous (iv) infusion mimicking the intranasal pharmacokinetic profile. In Part A, 12 early postpartum women received doses of either 4 μg (n = 6) or 16 μg (n = 6) of merotocin within 4 days of delivery. In Part B, six women with established lactation received 20 μg of merotocin. The total concentration of merotocin in plasma and breast milk and its metabolites excreted in breast milk were measured at various time points. Adverse events (AEs) were also assessed for both parts of the study. Results: In both early postpartum and established lactation groups (mean age, 26.3 years; 83.3% Caucasian), merotocin and its metabolites in breast milk were below the limit of quantification (25.0 pg/mL) at all time points. Sixteen treatment-emergent AEs occurred in early postpartum women only, including seven events of uterine spasm and three of breast engorgement. There was one moderate event, whereas all the other events were considered mild. Conclusion: Merotocin was undetectable in breast milk after single iv administration of up to 20 μg in early postpartum women and women with established lactation.

The diagnosis and prevalence of hypoprolactinemia in patients with panhypopituitarism and the effects on depression and sexual functions

PURPOSE

We aimed to investigate the prevalence and the diagnostic criteria of hypoprolactinemia in patients with panhypopituitarism and the effects of hypoprolactinemia on depression and sexual functions.

MATERIALS AND METHODS

Forty-eight patients with panhypopituitarism and 20 healthy volunteers were included. Basal hormone levels were measured and a TRH stimulation test was performed. For the evaluation of sexual functions, questionnaries of Female Sexual Functional Index (FSFI) for females and International Erectile Functional Index for males were performed to the subjects. Depressive symptoms were evaluated by Beck Depression Envontory score (BDI-II).

RESULTS

The peak PRL response to TRH stimulation test at 5th percentile in the control group was 18.6 ng/ml in males and 41.6 ng/ml in females and accepted as the cut-offs for sufficient response of PRL. Prolactin was insufficient in 42(87.5%) patients. A basal PRL level of ≤ 5.7 ng/ml in males and 7.11 ng/ml in females was 100% specific in predicting an inadequate response to TRH stimulation test with 80% and 70% sensitivity respectively. A basal PRL level of ≥ 8.5 ng/dl in males was 100% specific and 76% sensitive, and in females a level of ≥ 15.2 ng/dl was 96% specific and 66% sensitive in predicting an adequate response to TRH. PRL deficient patients with panhypopituitarism had higher depression scores compared to the controls, lower sexual function scores in males.

CONCLUSION

PRL deficiency is prevalent among individuals with panhypopituitarism, with the potential to result in elevated depression scores in both sexes and impaired sexual functions in males. A basal PRL level seems to be sufficient for the diagnosis of hypoprolactinemia in routine clinical practice.

The Potential of Chicken-Herb Essence to Improve Milk Production and Infant Health in the Sprague Dawley Animal Model

Breast milk serves as the primary source of nourishment for newborns. In cases of low milk production, one approach to address this challenge involves the consumption of lactagogues. Chicken-herb essence, a beverage rich in protein, amino acids, and minerals, presents itself as a viable option to supplement a lactating mother's diet, particularly in terms of protein intake. This study aimed to evaluate the effects of chicken-herb essence on prolactin and lactoferrin in lactating rats. Furthermore, the study also assessed the lactagogue effect on IgA in offspring. The experimental research method used a completely randomized design. The animal models in this study were female Sprague Dawley rats. The result showed that there was an increase in milk production, as seen from the results of the lactagogue effect. The highest increase in prolactin and lactoferrin was obtained in treatment group II (TG II). The increases in prolactin and lactoferrin of TG II were 214.18 ± 71.99 and 904.02 ± 435.35 pg/mL, respectively. The lactagogue test showed that TG II haspotency as a milk-booster. Testing the blood serum of offspring showed that the highest concentration of IgA was also found in TG II at 398.34 ± 214.85 pg/mL.

Non-Puerperal Adoptive Breastfeeding as Lactational Rescue in the Rohingya Refugee Camp: 2 Case Studies

INTRODUCTION

Non-puerperal adoptive lactation sometimes requires long preparation and substantial expense for pharmacological intervention to be successful, which are not feasible in refugee camps. Here we report two case studies of non-puerperal adoptive breastfeeding of two infants in the Rohingya Refugee Camp of Cox's Bazar, Bangladesh.

MAIN ISSUE

Two non-pregnant, non-breastfeeding caregivers with previous experience of breastfeeding brought two adopted infants-one a 12-day-old female with severe acute malnutrition, and the other a 2-day-old male with normal anthropometric measurements-to a nutritional stabilization center for feeding. After counseling, both families opted for adoptive lactation.

MANAGEMENT

Both infants were treated with a modified Action Against Hunger protocol of in-patient management of severe acute malnutrition using the supplementary suckling technique, a procedure to feed the baby with supplementary feed. Diluted F100 was used as the supplementary feed; the energy and protein gained from it were just enough to maintain body physiology and were not responsible for any weight gain. When the infants gained weight, indicating that the caregivers were producing milk, we reduced the supplementary feed as per protocol guidelines. The caregivers were prescribed domperidone and counseled on their ability to breastfeed the infants. The cases required 35 days and 20 days, respectively, for the full establishment of breastfeeding.

CONCLUSION

This is the first report of successful adoptive breastfeeding in a refugee camp. With proper counseling and motivation of the caregiver, induced lactation can be started without a preparatory period and with very low-cost intervention.

Bioactive peptides in preterm human milk: Impact of maternal characteristics and their association to neonatal outcomes

Human milk adipokines in term babies seem partially determined by maternal factors and affect infant's development. We aimed to describe bioactive peptide concentration in very preterm human milk and associations to maternal characteristics and postnatal growth. Mothers delivering ≤32 weeks of gestation and their infant/s were recruited. At 4 weeks of lactation, an aliquot of 24-h-pooled milk was collected for exclusively breastfeeding dyads. Insulin, leptin, adiponectin, and milk fat globule epidermal growth factor-8 (MFG-E8) were measured by enzyme-linked immunoabsorbent assay in skimmed milk. One hundred mothers (28.8 ± 2.3 weeks at delivery) provided a milk sample. Milk insulin was related to gestational age, pre-pregnancy body mass index (BMI), and galactagogue treatment (final model: adjusted R2 : 0.330, p < 0.0001; adjusted β coefficients: galactagogue treatment: 0.348, p 0.001; pre-pregnancy BMI: 0.274, p 0.009; gestational age: -0.290, p 0.007). Adiponectin was higher in mothers with gestational diabetes (30.7 ± 6.5 vs. 24.8 ± 8 ng/mL, p 0.044). Leptin was associated with pre-pregnancy BMI (Spearman's ρ: 0.648, p < 0.0001) and MFG-E8 to presence of labor and multiple pregnancy (final linear regression model, R2 : 0.073, p 0.028, adjusted β coefficients: presence of labor -0.229, p 0.050; twins: -0.192, p 0.099). Milk adiponectin was associated with a greater decrease in length z-scores from birth to 28 days (Pearson's r: -0.225, p 0.032) and to discharge (Pearson's r: -0.290, p 0.003). Milk MFG-E8 was lower in milk of mothers whose babies experienced late-onset sepsis (13.3 ± 5.8 vs. 16.8 ± 6.3 μg/mL, p 0.023). Adipokines levels in preterm human milk are partially related to maternal metabolic status. Milk peptide concentration associates with early neonatal growth trajectories.

Attitudes and counselling of healthcare professionals on increasing breast milk: cross-sectional study

OBJECTIVE

To determine the breast milk-increasing practices healthcare professionals used with their children and their recommendations to mothers.

METHOD

A descriptive cross-sectional study in a Mediterranean region of Turkey. It was carried out with 301 healthcare professionals working in 64 Family Health Centers between January and June 2018. The data were collected by the researchers with a questionnaire including 28 questions.

RESULTS

The mean age of healthcare professionals was 36.89 ± 8.5. All the healthcare professionals encountered mothers with the perception of insufficient breast milk. 73.7% of those with children had breast milk-increasing practices. Increased age negatively affected these practices (OR: 0.923), and increased education positively affected the practices (OR: 3.489). Having received training on breastfeeding and breast milk-increasing measures positively affected the use of practices (OR: 2.118). The use of breast milk-increasing practices by healthcare professionals positively affected their recommendations to mothers (OR: 2.506).

CONCLUSIONS

Health professionals had their own breast milk boosting practices that they recommended to women as well. This result is especially significant in terms of guiding mothers who wish to increase breast milk supply and seek reliable information and contributes to the protection of maternal and newborn health.

Parental factors that impact the ecology of human mammary development, milk secretion, and milk composition-a report from "Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)" Working Group 1

The goal of Working Group 1 in the Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN) Project was to outline factors influencing biological processes governing human milk secretion and to evaluate our current knowledge of these processes. Many factors regulate mammary gland development in utero, during puberty, in pregnancy, through secretory activation, and at weaning. These factors include breast anatomy, breast vasculature, diet, and the lactating parent's hormonal milieu including estrogen, progesterone, placental lactogen, cortisol, prolactin, and growth hormone. We examine the effects of time of day and postpartum interval on milk secretion, along with the role and mechanisms of lactating parent-infant interactions on milk secretion and bonding, with particular attention to the actions of oxytocin on the mammary gland and the pleasure systems in the brain. We then consider the potential effects of clinical conditions including infection, pre-eclampsia, preterm birth, cardiovascular health, inflammatory states, mastitis, and particularly, gestational diabetes and obesity. Although we know a great deal about the transporter systems by which zinc and calcium pass from the blood stream into milk, the interactions and cellular localization of transporters that carry substrates such as glucose, amino acids, copper, and the many other trace metals present in human milk across plasma and intracellular membranes require more research. We pose the question of how cultured mammary alveolar cells and animal models can help answer lingering questions about the mechanisms and regulation of human milk secretion. We raise questions about the role of the lactating parent and the infant microbiome and the immune system during breast development, secretion of immune molecules into milk, and protection of the breast from pathogens. Finally, we consider the effect of medications, recreational and illicit drugs, pesticides, and endocrine-disrupting chemicals on milk secretion and composition, emphasizing that this area needs much more research attention.

Aripiprazole, brexpiprazole, and cariprazine can affect milk supply: Advice to breastfeeding mothers

OBJECTIVE

We sought to review the effects of Dopamine Receptor Partial Agonist (DRPA) antipsychotic medications on milk supply and breastfeeding.

METHOD

Narrative review of selected literature including animal and human data.

RESULTS

Scant case study evidence suggests that DRPAs may lead to reduced milk supply for some.

CONCLUSIONS

Women taking DRPAs should be advised of the possibility that these may affect milk supply, and reporting should be encouraged to aid future research.

Women's experiences with using domperidone as a galactagogue to increase breast milk supply: an australian cross-sectional survey

BACKGROUND

Domperidone is one of the most commonly utilised pharmacological galactagogues, with evidence of increasing use in clinical practice. However, the use of domperidone as a galactagogue remains controversial, with mixed evidence on safety and efficacy, leading to variable clinical practice recommendations. We sought to evaluate contemporary patterns of domperidone use and examine maternal experiences related to perceived safety and effectiveness.

METHODS

In 2019, we conducted an online, cross-sectional survey of Australian breastfeeding women to examine individual experiences related to domperidone use, in addition to perceptions of safety and effectiveness.

RESULTS

Among 1876 survey responses, 19% (n = 355) reported using domperidone. Domperidone use was significantly higher in women who were primiparous, gave birth preterm, delivered by caesarean section, had self-perceived low milk supply, and saw a lactation consultant. Nearly 20% of women commenced domperidone use in the first week postpartum (19%, n = 67). The median duration of use was six weeks (interquartile range 3-16 weeks). Maximum reported doses of domperidone used ranged from 20 mg/day to 160 mg/day. Half (n = 178, 50%) of women reported using a dose of 30 mg/day or less, 44% (n = 155) reported using a dose between 31 and 60 mg/day, and 6% (n = 22) reported using a dose greater than 61 mg/day. Nearly half of the respondents reported domperidone as 'very' or 'extremely effective' (45%, n = 161), with only 8% (n = 27) reporting it was 'not at all effective'. Almost half (n = 172, 48%) of all women using domperidone reported side effects, including weight gain (25%), headaches (17%) and dry mouth (13%). Higher doses were associated with an increased likelihood of any side effects (≤ 30 mg/day, 38%; >31-≤60 mg/day, 48%, > 61 mg/day 73%; P < 0.004), with 31 (9%) stopping domperidone because of side effects.

CONCLUSION

We identified widespread variation in domperidone utilisation patterns, with domperidone broadly perceived to be effective in increasing breast milk supply. Side effects associated with domperidone treatment were common, appeared to be dose-related, and were frequently associated with treatment cessation. These findings highlight the importance of improved clinical practice recommendations and generation of evidence from additional high-quality clinical trials evaluating the efficacy and safety of domperidone. More conclusive clinical trials are needed to determine the efficacy, as well as optimal dose and duration, of domperidone use.

The Galactagogue Effect of Maternal Ingestion of Corn-Based Preparations: A Preliminary Study

Background: Low human milk production frequently occurs in mothers of premature children with low birth weights who require intensive care. Research Aims: To investigate whether corn-based preparations increase human milk production in women with insufficient milk volumes. Method: This was an intervention study evaluated whether there was an increase in human milk production after a mother's consumption of corn-based preparations. The participants included women with hypogalactia and mothers of infants in neonatal and pediatric intensive care units. The corn-based preparations included green corn cakes and sweet hominies. A total of 35 mother-infant pairs participated in this study. Each mother served as their own control. The study took place over 2 weeks, and data were collected at baseline and after the intervention. At baseline, a socioeconomic questionnaire was used to collect information regarding maternal food consumption, volume of milk expressed, and infant weight and length. All evaluations, except for questionnaire administration, were performed during the intervention phase, when the lactating women ingested the corn-based preparations. Results: A significantly higher average volume of milk was expressed in the intervention period (397.6 ± 182.6 mL/day) compared to baseline (343.6 ± 155.8 mL/day) on the paired t-test (p < 0.001) analysis. Neither energy nor macronutrients consumed correlated with milk volume. Conclusion: The tested corn-based preparations acted as galactagogues and could be used to stimulate milk production in lactating women.

Domperidone Use as a Galactagogue and Infanticide Ideation: A Case Report

Objectives: Domperidone is an antiemetic that is commonly used as an off-label prescription to induce lactation. Neuropsychiatric adverse effects of domperidone such as akathisia and depression are previously described. It has never been reported to be associated with infanticide ideation. The aim of this article is to discuss the occurrence of infanticide ideation following domperidone usage in an adoptive mother and the potential mechanisms by which these may occur. Methods: With Institutional Review Board approval, we herein report a nulliparous adoptive mother who developed infanticide ideation after 3 months of exposure to domperidone. The infanticide ideation was intrusive, recurrent, ego-dystonic, causing significant depressive symptoms and affecting the patient's functions. Physical examination and relevant biological investigations were unremarkable. Results: The patient is treated as domperidone-induced obsessional thought with adjustment disorder. The domperidone was stopped immediately. Serotonin and norepinephrine reuptake inhibitors was started. The infanticide ideation gradually resolved and patient achieved complete remission after 10 months of treatment. Conclusion: The infanticide ideation following consumption of domperidone is a potential neuropsychiatric adverse event that warrants further examination into the safety of domperidone as an "off-labeled" galactagogue. Comprehensive psychological assessment of mother who wishes to use domperidone as galactagogue is recommended.

Common Complications of Breastfeeding and Lactation: An Overview for Clinicians

Lactation and breastfeeding are core components of reproductive health care and obstetrical providers should be familiar with common complications that may arise in lactating individuals. While many breastfeeding challenges are best addressed by a lactation consultant, there are conditions that fall out of their scope and require care from a clinician. The objective of this chapter is to review common complications of breastfeeding and lactation including inflammatory conditions, disorders of lactogenesis, dermatologic conditions, and persistent pain with lactation.

Galactagogues and Lactation: Considerations for Counseling Breastfeeding Mothers

ABSTRACT

Development of a milk supply is a complex process that is not always understood by women who are breastfeeding. Galactagogues are substances commonly used by breastfeeding women who perceive that they have an insufficient milk supply. They can be herbal substances or pharmaceuticals. Herbal galactagogues are advertised and sold to women as capsules, cookies, milk shakes, and teas, as well as other forms of herbal supplements. Herbal galactagogues are classified as dietary supplements and not reviewed or regulated by the U.S. Food and Drug Administration. There are limited data on their safety and efficacy. Women experiencing problems with their milk supply should receive a thorough and thoughtful assessment of the situation. There are many factors that should be considered when counseling breastfeeding women about use of galactagogues. The physiology of lactation, process of milk supply development, and the evidence for use of galactagogues are reviewed to add to the knowledge of nurses and other health care providers working with women who are breastfeeding.

Lactational Amenorrhea: Neuroendocrine Pathways Controlling Fertility and Bone Turnover

Lactation is a physiological state of hyperprolactinemia and associated amenorrhea. Despite the fact that exact mechanisms standing behind the hypothalamus-pituitary-ovarian axis during lactation are still not clear, a general overview of events leading to amenorrhea may be suggested. Suckling remains the most important stimulus maintaining suppressive effect on ovaries after pregnancy. Breastfeeding is accompanied by high levels of prolactin, which remain higher than normal until the frequency and duration of daily suckling decreases and allows normal menstrual function resumption. Hyperprolactinemia induces the suppression of hypothalamic Kiss1 neurons that directly control the pulsatile release of GnRH. Disruption in the pulsatile manner of GnRH secretion results in a strongly decreased frequency of corresponding LH pulses. Inadequate LH secretion and lack of pre-ovulatory surge inhibit the progression of the follicular phase of a menstrual cycle and result in anovulation and amenorrhea. The main consequences of lactational amenorrhea are connected with fertility issues and increased bone turnover. Provided the fulfillment of all the established conditions of its use, the lactational amenorrhea method (LAM) efficiently protects against pregnancy. Because of its accessibility and lack of additional associated costs, LAM might be especially beneficial in low-income, developing countries, where modern contraception is hard to obtain. Breastfeeding alone is not equal to the LAM method, and therefore, it is not enough to successfully protect against conception. That is why LAM promotion should primarily focus on conditions under which its use is safe and effective. More studies on larger study groups should be conducted to determine and confirm the impact of behavioral factors, like suckling parameters, on the LAM efficacy. Lactational bone loss is a physiologic mechanism that enables providing a sufficient amount of calcium to the newborn. Despite the decline in bone mass during breastfeeding, it rebuilds after weaning and is not associated with a postmenopausal decrease in BMD and osteoporosis risk. Therefore, it should be a matter of concern only for lactating women with additional risk factors or with low BMD before pregnancy. The review summarizes the effect that breastfeeding exerts on the hypothalamus-pituitary axis as well as fertility and bone turnover aspects of lactational amenorrhea. We discuss the possibility of the use of lactation as contraception, along with this method's prevalence, efficacy, and influencing factors. We also review the literature on the topic of lactational bone loss: its mechanism, severity, and persistence throughout life.

Mothers in Need of Lactation Support May Benefit from Early Postnatal Galactagogue Administration: Experience from a Single Center

Background: Galactagogues are substances that promote lactation, although data on their effects on humans remain limited. We investigated the efficacy of Silitidil to increase milk supply and duration of breastfeeding of a specific subgroup of mothers in need of lactation support. Methods: 161 mothers from November 2018 until January 2021 were the study subjects in this retrospective study; during their hospitalization, due to neonatal or maternal factors that inhibited lactation, they were prescribed galactagogues. Mothers were surveyed by telephone interview via a 13-item questionnaire. Results: 73.91%, were primigravidas, 78.26% gave birth by cesarean section (CS) and 72.05% continued to take galactagogues after hospital discharge. Of the neonates, 24.22% were preterm ≤37 weeks of gestation, and 55.9% had birth weight (BW) between 2500 and 3500 g. With respect to breastfeeding rates, 100% were breastfed during their first week, 98.8% breastfed during the first month, 87% during the first 4 months, dropping to 56.5% at 6 months, 41% at 1 year and 19.3% over 1 year of age. Conclusions: This study demonstrates that administration of a galactagogue containing Silitidil (Piulatte-Humana) improves breastfeeding rates at from 1 until 12 months of life in mothers with low milk supply during their hospital stay. Further studies are needed to generate evidence-based strategies to improve breastfeeding outcomes.

"Fear of stopping" vs "wanting to get off the medication": exploring women's experiences of using domperidone as a galactagogue - a qualitative study

Background

Domperidone is the most frequently prescribed medicine used to increase breast milk supply. There is considerable controversy surrounding the use of domperidone in lactation, due to limited evidence about efficacy and concerns about rare but life-threatening side-effects. Despite this, in many high-income settings such as Australia, use of domperidone among breastfeeding mothers appears to be increasing. The aim of this paper was to explore women’s experiences of using domperidone during breastfeeding.

Methods

Semi-structured interviews were conducted in 2019 with 15 women in Australia who reported using domperidone as a galactagogue during breastfeeding. Interviews were recorded, transcribed and analysed thematically.

Results

Women reported a wide variety of practices concerning the timing of initiation of domperidone use, including prophylactic use, as well as the dose and duration of use. Prolonged periods of use and unsupervised dosing were commonly reported, these practices were sometimes associated with a fear of the consequences of stopping, insufficient provision of information about the drug or feeling dismissed by health professionals. Some women indicated that when doctors refused to prescribe domperidone they responded by doctor shopping and seeking anecdotal information about benefits and risks online, leading to unsupervised practices. Women often reported high expectations surrounding the effectiveness of domperidone, and most used the medication in conjunction with food/herbal galactagogues and non-galactagogue support. Positive outcomes following domperidone use included having greater confidence in breastfeeding and pride at achieving breastfeeding goals.

Conclusions

This study identified a variety of practices concerning domperidone use, including potentially unsafe practices, linked in some cases to inconsistent advice from health professionals and a reliance on online, anecdotal information sources. These findings emphasise the urgent need for development of clinical practice guidelines and a greater focus on translating existing evidence concerning domperidone into clinical practice, including clinical support that is tailored to women’s needs.

Traditional plant use during lactation and postpartum recovery: Infant development and maternal health roles

ETHNOPHARMACOLOGICAL RELEVANCE

Evidence of phytochemical roles in infant development and maternal recovery offers insights into beneficial functions of traditional plant use during lactation and the postpartum period. Ethnopharmacological research has relevance to global priorities on maternal and child health, to understanding origins and determinants of human self-medication, and for reconciling traditional postpartum practices and mainstream healthcare.

AIM OF THE STUDY

Present emerging evidence, within evolutionary and socio-cultural contexts, on the role of maternal consumption on transfer of phytochemicals into breast milk with impacts on maternal and child health, and on infant development. Establish current state of knowledge and an ethnopharmacological research agenda that is attentive to cross-cultural and regional differences in postpartum plant use.

MATERIALS AND METHODS

An extensive literature review using Medline, Scopus, and Web of Science focused on traditional and contemporary use and socio-cultural context, as well as physiological, pharmacological, toxicological, and behavioral activities of plants used medicinally by women during postpartum recovery and lactation.

RESULTS

The most widely reported postpartum plants show antimicrobial, anti-inflammatory, immunological, and neurophysiological activities, with low toxicity. Phytochemicals transfer from maternal consumption into breast milk in physiological concentrations, while animal studies demonstrate immunomodulation and other actions of medicinal plants during lactation. Reporting on the use and diverse traditional knowledge of women about plants during the postpartum period is obscured by the marginal place of obstetric issues and by gender biases in ethnobotanical research. In many contemporary contexts use is prejudiced by precautionary risk warnings in health literature and practice that confound lactation with pregnancy.

CONCLUSIONS

Although systematic investigation of postpartum plant use is lacking, known pharmacological activities support potential benefits on infant development and maternal health with immediate and long-term consequences in relation to allergic, inflammatory, autoimmune, and other diseases. An ethnopharmacological agenda focused on the perinatal period requires directed methodologies and a regional approach in relation to culturally-specific knowledge and practices, traditional plant use, and local health needs. Testing the hypothesis that phytochemicals transferred from medicinal plants into breast milk impact the human immune system and other aspects of infant development requires extended analysis of phytochemicals in human milk and infant lumen and plasma, as well as effects on gastrointestinal and milk microbiome.

Impaired Lactation: Review of Delayed Lactogenesis and Insufficient Lactation

It is estimated that as many as 1 in 20 women worldwide are unable to successfully breastfeed or provide adequate nutrition for their infants through their breast milk alone. Compromised nutrition in the early stages of life places the infant at risk for insufficient growth as well as serious and potentially disabling or life-threatening complications. This review summarizes risk factors associated with impaired lactation that may result in either delayed lactogenesis or insufficient lactation. The risk factors for insufficient lactation are categorized into preglandular, glandular, and postglandular causes. Impaired lactation can occur despite maternal motivation, knowledge, support, and appropriate breastfeeding technique. Although there is no clear way to predict who will experience impaired lactation, knowledge about the risk factors can enable health care professionals to better identify at-risk mother-infant dyads. Early intervention may help prevent infant complications associated with inadequate nutritional intake.

25 Years of Research in Human Lactation: From Discovery to Translation

Researchers have recently called for human lactation research to be conceptualized as a biological framework where maternal and infant factors impacting human milk, in terms of composition, volume and energy content are studied along with relationships to infant growth, development and health. This approach allows for the development of evidence-based interventions that are more likely to support breastfeeding and lactation in pursuit of global breastfeeding goals. Here we summarize the seminal findings of our research programme using a biological systems approach traversing breast anatomy, milk secretion, physiology of milk removal with respect to breastfeeding and expression, milk composition and infant intake, and infant gastric emptying, culminating in the exploration of relationships with infant growth, development of body composition, and health. This approach has allowed the translation of the findings with respect to education, and clinical practice. It also sets a foundation for improved study design for future investigations in human lactation.

Study and Experimental Validation of the Functional Components and Mechanisms of Hemerocallis citrina Baroni in the Treatment of Lactation Deficiency

The function of Hemerocallis citrina Baroni (daylily) on promoting lactation is reported in several ancient Chinese medicine books. However, nowadays, there is no conclusive data to support this statement. In this study, we investigated the effect of Hemerocallis citrina Baroni extract (HCE) on lactation insufficiency in chronic unpredictable mild stress (CUMS) dams and further explored the mechanism and functional components through network pharmacology. The results showed that HCE could increase the offspring’s weight, serum prolactin (PRL), and oxytocin (OT) level of CUMS dams. Network pharmacology analysis revealed that the facilitation of HCE on lactation is the result of the comprehensive action of 62 components on 209 targets and 260 pathways, among this network, quercetin, kaempferol, thymidine, etc., were the vital material basis, signal transducer and activator of transcription 3 (STAT3), mitogen activity protein kinase 1 (MAPK1), tumor protein P53 (TP53), etc., were the core targets, and the prolactin signaling pathway was the core pathway. In addition, verification test results showed that HCE regulated the abnormal expression of the prolactin signaling pathway, including STAT3, cyclin D1 (CCND1), MAPK1, MAPK8, nuclear factor NF-kappa-B p105 subunit (NFKB1), and tyrosine-protein kinase (JAK2). In conclusion, HCE exhibited a facilitation of lactation insufficiency, in which quercetin, kaempferol, thymidine, etc., were the most important material basis. The mechanism of this promotional effect is mediated by the prolactin signaling pathway in mammary gland.

Dietary Arginine Supplementation during Gestation and Lactation Increases Milk Yield and Mammary Lipogenesis in Rats

BACKGROUND

Arginine, an essential amino acid during the reproductive period, has been shown to enhance lactation performances in livestock. Whether it could help mothers with breastfeeding difficulties is not known.

OBJECTIVES

This study aimed to determine whether dietary arginine supplementation would enhance milk production in rat dams nursing large 12-pup litters and, if so, what mechanisms are involved.

METHODS

In 3 series of experiments, differing in dam killing timing, 59 primiparous, pregnant Sprague-Dawley rats (mean ± SD weight: 254 ± 24.7 g) were randomly assigned to receive either 1) an AIN-93G diet supplemented with l-arginine at 2.0% (ARG diet), through lactation and gestation (AGL group); 2) a control AIN-93G diet including at 3.5% an isonitrogenous mix of amino acids that are not essential for lactation (MA diet), during gestation and lactation (MA group); or 3) the MA diet during gestation and the ARG diet during lactation (AL group). Milk flow was measured using deuterated water enrichment between days 11 and 18. Plasma hormones and mammary expression of genes involved in lactation were measured using ELISA and qRT-PCR, respectively, at lactation days 12, 18, or 21 in the 3 experiments. Data were analyzed by ANOVA.

RESULTS

Dam food intake, pup weight gain, milk flow normalized to dam weight, and milk fat concentration were 17%, 9%, 20%, and 20% greater in the AGL group than in the MA group, respectively (P < 0.05). Genes involved in lipogenesis and lipid regulation were overexpressed ≤2.76-fold in the mammary gland of AGL dams compared with MA dams (P < 0.05) and plasma leptin concentration was 39% higher (P = 0.008). Milk flow and composition and mammary gene expression of the AL group did not differ from those of the MA group, whereas milk fat concentration and flow were 26% and 37% lower than in the AGL group, respectively.

CONCLUSIONS

Arginine supplementation during gestation and lactation enhances milk flow and mammary lipogenesis in rats nursing large litters.

Ethanol Extract of Carica papaya Leaf Can Increase Breast Milk in Lactating Rat

BACKGROUND: Carica papaya leaves (Carica papaya L) have been used empirically and traditionally as a galactogogue, but their mechanism as galactogogue is still unknown. AIM: This study aimed to analyze the effect of ethanol extract from papaya leaves on blood prolactin levels, prolactin receptor (prlr) gene expression, the number of breast alveoli and lobes of lactating rats. METHODS: This in vivo true experimental study with a post-test control group design was conducted on 24 rats with the same lactating period. They were divided into four groups consisting of six rats each. The control group was given daily standard food, whereas the three treatment groups were, respectively, given additionally ethanol extract of 0.95 mg, 1.9 mg, and 3.8 mg/200 g BW/day from day 1 to day 14 of lactation. On day 14, all of the rats were sacrificed, blood prolactin levels were measured by ELISA, prlr gene expressions were measured using RT-PCR, and numbers of breast alveoli and lobes were microscopically observed through staining histological specimens. A statistical analysis was carried out using one-way ANOVA, Tukey's test, Games–Howell test, and path analysis at 95% confidence level. RESULTS: Levels of blood prolactin levels, prlr gene expression, the number of breast alveoli, and lobes of all treatment rat groups were significantly above those of the control group (p < 0.05). The increases of all parameters were consistent; the most effective dose was 1.9 mg/200 g BW. CONCLUSION: The Carica papaya leaf ethanol extract had a galactogogue effect on lactating rats by increasing blood prolactin levels, prlr gene expression, and numbers number of breast alveoli and lobes.

Efficacy and Safety of Domperidone and Metoclopramide in Breastfeeding: A Systematic Review and Meta-Analysis

Objectives: To evaluate the efficacy and safety of domperidone and metoclopramide used by breastfeeding women. Methods: A systematic literature search retrieved citations from PubMed, Embase, The Cochrane Library, Medline, EBSCO, Web of Science, ClinicalTrials.gov (from inception to January, 2021) and bibliographies of known articles. Randomized controlled trials exploring the effects of domperidone and metoclopramide in breastfeeding women with term and preterm infants experiencing adequate or low milk supply were identified. Human milk volume and maternal side effects were presented as mean difference (MD) or relative risks (RR) with 95% confidence intervals (CI). Results: Sixteen trials involving 729 women were included in the qualitative analysis and 14 trials involving 607 women were included in the meta-analysis. In mothers of preterm infants with low milk supply, domperidone demonstrated a significant increase in daily human milk volume (MD = 90.53 mL/day, 95% CI [65.42 to 115.64], I² = 9%). However, metoclopramide did not show significant difference in daily human milk volume in women with preterm infants (MD = -1.14 mL/day, 95% CI [-31.42 to 29.14], I² = 0%). No differences in maternal side effects were noted with domperidone (RR = 1.20, 95% CI [0.74 to 1.97], I² = 0%) or metoclopramide (RR = 1.05, 95% CI [0.52 to 2.11], I² = 27%) in women with preterm infants. Regarding the women with term infants, there were insufficient data in the current review. Conclusions: Domperidone can be used to treat low milk supply in women with preterm infants without significant side effects based on the current review. More evidence exploring the efficacy and safety of domperidone and metoclopramide are still needed for breastfeeding women in the future.

Use and experiences of galactagogues while breastfeeding among Australian women

Background

Galactagogues are substances thought to increase breast milk production, however evidence to support their efficacy and safety remain limited. We undertook a survey among Australian women to examine patterns of use of galactagogues and perceptions regarding their safety and effectiveness.

Methods

An online, cross-sectional survey was distributed between September and December 2019 via national breastfeeding and preterm birth support organisations, and networks of several research institutions in Australia. Women were eligible to participate if they lived in Australia and were currently/previously breastfeeding. The survey included questions about galactagogue use (including duration and timing), side effects and perceived effectiveness (on a scale of 1 [Not at all effective] to 5 [Extremely effective]).

Results

Among 1876 respondents, 1120 (60%) reported using one or more galactagogues. Women were 31.5 ± 4.8 years (mean ± standard deviation) at their most recent birth. Sixty-five percent of women were currently breastfeeding at the time of the survey. The most commonly reported galactagogues included lactation cookies (47%), brewer’s yeast (32%), fenugreek (22%) and domperidone (19%). The mean duration of use for each galactagogue ranged from 2 to 20 weeks. Approximately 1 in 6 women reported commencing galactagogues within the first week postpartum. Most women reported receiving recommendations to use herbal/dietary galactagogues from the internet (38%) or friends (25%), whereas pharmaceutical galactagogues were most commonly prescribed by General Practitioners (72%). The perceived effectiveness varied greatly across galactagogues. Perceived effectiveness was highest for domperidone (mean rating of 3.3 compared with 2.0 to 3.0 among other galactagogues). Over 23% of domperidone users reported experiencing multiple side effects, compared to an average of 3% of women taking herbal galactagogues.

Conclusions

This survey demonstrates that galactagogues use is common in Australia. Further research is needed to generate robust evidence about galactagogues’ efficacy and safety to support evidence-based strategies and improve breastfeeding outcomes.

The risk-risk trade-offs: Understanding factors that influence women's decision to use substances to boost breast milk supply

Galactagogues are foods, herbs or medications thought to support or increase breast milk supply. The use of galactagogues during lactation is becoming increasingly common despite limited evidence regarding effectiveness and safety, and no definitive recommendations for use in clinical practice. The aim of this study is to explore factors influencing women's decisions to use galactagogues during lactation. Twenty-two semi-structured interviews were conducted in October and November 2019 (over the telephone or in person) with participants located in most Australian states and territories, including metro and regional areas. Interviews were audio-recorded, transcribed verbatim and thematically analysed using NVivo. Analysis revealed that following a concern about breast milk supply, the decision to use galactagogues was influenced by three core and interrelated domains: access to and quality of breastfeeding support, maternal agency and determination to provide breast milk. Women revealed many problematic experiences with health care professionals that left them feeling dismissed and confused due to provision of inconsistent and insufficient information that was sometimes at odds with their desire to provide breast milk. In this instance, some women turned to galactagogues to regain agency. A range of broader dimensions influencing decision-making also emerged. These were separated into categories that emphasise distinctions relating to breast milk supply, which included: maternal emotional wellbeing, social norms and pressures, concerns about infant development, maternal physical health and lactation history, as well as those relating specifically to galactagogue use, including: desire for a guaranteed/urgent response, risk-risk trade-off, acceptance and trust, and accessibility and cost. In understanding the complexity of decision-making concerning these substances, we identify opportunities to improve breastfeeding counselling and support. We recommend that support be individually tailored to manage conflicting information, adopt communication styles that encourage trust and processes that enable shared decision-making to enhance or restore maternal agency. There is also considerable need to address evidence gaps regarding the effectiveness and safety of commonly used galactagogues, so that women can be appropriately counselled about potential benefits and harms.

Effect of Hordei Fructus Germinatus on differential gene expression in the prolactin signaling pathway in the mammary gland of lactating rats

ETHNOPHARMACOLOGICAL RELEVANCE

In China, Hordei Fructus Germinatus (HFG) is the germinated and dried fruit of Hordeum vulgare L, which is commonly used in clinical Chinese medicine. Traditional Chinese Medicine (TCM) theory holds that HFG can be both medicinal and edible, which means that it is derived from food medicine. Raw HFG and roasted HFG are used to treat hypogalactia, hyperprolactinemia and indigestion. In recent years, the lactogenic and galactophygous effects of HFG have attracted increasing attention. Nevertheless, there is much confusion over the use of raw and processed HFG, and the mechanism of its lactogenic effect seems remains poorly understood.

AIM OF THE STUDY

This study aimed to explore the lactogenic effect of raw HFG and roasted HFG on rats with overloaded lactation and to reveal the underlying molecular mechanism.

MATERIALS AND METHODS

Raw and processed HFG water decoctions were given to overloaded lactation model rats at a dose of 1.7800 g kg^-1·d^-1, and the control group was given the same volume of water. The lactogenic effect of raw and processed HFG was evaluated by measuring daily lactation, body weight and pup body weight, serum PRL, E2, and GH contents after parturition, and the pathological characteristics of mammary tissue sections. cDNA microarrays can be used to screen diverse gene expression patterns and signaling pathways related to prolactin. The expression of relevant differentially expressed genes was verified by real-time PCR and western blotting.

RESULTS

In vivo experiments demonstrated that the raw HFG water decoction stimulated mammogenesis, accelerated the transformation of the lobular acinar system, resulted in denser mammary epithelial cells and thicker glandular ducts that were full of milk and facilitated the secretion of milk. Moreover, HFG increased PRL, E2, and GH levels, pup body weight, daily lactation and the body weight of lactating rats. Following gene chip identification, KEGG pathway enrichment analysis revealed genes that were highly related to prolactin in the prolactin signaling pathway and JAK-STAT signaling pathway, and the main differentially expressed genes were Jak2 (down), Stat5α (up), cyclin D1 (up), SOCS1 (up), CISH (down) and PRLR (up). Compared with the control group, RT-PCR results indicated that Jak2 and CISH were downregulated and that Stat5α, cyclin D1, SOCS1 and PRLR were upregulated. Western blot assays showed that PRLR, STAT5α and cyclin D1 levels in the mammary glands of the raw HFG water decoction group were significantly increased, which was consistent with the results of cDNA microarray screening.

CONCLUSION

The present study reveals that raw HFG effectively enhances lactation in rats, possibly by influencing the prolactin/JAK-STAT signaling pathway.

Effect of Domperidone on Breast Milk Production in Mothers of Sick Neonates: A Randomized, Double-Blinded, Placebo-Controlled Trial

Objective: Mothers of many preterm babies are unable to produce sufficient milk for their babies during the prolonged hospitalization. Domperidone stimulates the release of prolactin, thereby increasing breast milk production. The primary outcome was to study the efficacy of domperidone in augmenting breast milk production in mothers with lactation failure (LF). The secondary outcomes included the effect of domperidone on prolactin levels, adverse effects of domperidone, and outcome on breastfeeding rates at discharge. Materials and Methods: This was a randomized, double-blinded, placebo-controlled trial where mothers with LF were either allocated domperidone (10 mg) or placebo, 2 tablets three times a day for 14 days. Milk volumes were recorded daily for 14 days. Serum prolactin levels were measured at the start and at day 7 of study. Results: Out of 166 women eligible for the study, 119 (71.7%) mothers were able to increase their breast milk production without pharmacological treatment after being counseled on the advantages of human milk and proper breastfeeding management. Forty-seven mothers were finally enrolled in the study; 24 in the domperidone group (DG) and 23 in the placebo group (PG). Breast milk production increased from a baseline of 156 + 141.1 to 400.9 + 239.2 mL in the DG and increased from a baseline of 175.8 + 150.7 to 260.5 + 237.5 mL in the PG, after 14 days (p < 0.01). The prolactin levels in the DG and PG increased from 72.85 (22.2-167.15) and 42.33 (14.02-93.54) ng/mL, respectively, to 223.4 (49.79-280.2) ng/mL (p = 0.005) in the DG and 60.08 (14.31-132.14) ng/mL (p = 0.232) in the PG on the 7th day of treatment. No adverse effects were recorded. Ninety-five percent of babies in the DG were exclusively breastfeeding at hospital discharge, compared with 52.4% in the PG (p = 0.008). Conclusion: Domperidone treatment can result in an increase in breast milk production with no adverse effects. The study was registered with the Thai Clinical Trials Registry ID TCTR2020091008.

Special foods and local herbs used to enhance breastmilk production in Ghana: rate of use and beliefs of efficacy

Background

Inadequate breastmilk production is one of the key factors associated with suboptimal breastfeeding. In most local African homes, special herbs and some food items are commonly used to promote breastmilk production (known as lactogogue/galactogogue). We describe the use and characterize the herbs and food items used to promote breastmilk production in two regions of Ghana.

Methods

We conducted a cross-sectional study in 2018 involving 402 lactating mothers. The range of foods used as lactogogues was obtained from 20 participants through focus group discussions. Quantitative data on demographics, lactogogue use and feeding practices were obtained through questionnaire administration.

Results

The mean age of women was 29.2 years and children were 10 months. Breastmilk production problems were low (22.4%) and the majority of lactating mothers felt they had adequate breastmilk (70.4%) but awareness about lactogogues was widespread in both regions (88.8%) and highest in the Brong-Ahafo region (90.0%). Information about lactogogues was mainly from grandparents (24.6%), parents (31.6), health facilities (16.5%) and friends (12.8%), while the media had little influence (< 1%). The majority of the mothers used lactogogues to enhance breastmilk production (67.7%), and a quarter of them used lactogogues because of their tradition (25.2%). Prevalence of lactogogue use was 83.8%, lactogogues were prepared separate from household meals (59.4%) and consumed one to three times a day (89.6%). Users felt the effectiveness within 24 h of use (98.5%). The most common lactogogues included; groundnut/peanut soup prepared with Bra leaves (Hibiscus sabdariffa), hot black tea, Werewere/Agushi (Citrulus colocynthis) prepared with Bra leaves, and Abemudro (a polyherbal formulation). Only 13.2% of lactating mothers also used lactogogues during pregnancy.

Conclusions

Special foods and selected herbs are widely used to enhance breastmilk production in Ghana and constitute an important part of the diet of lactating mothers. These results could contribute to understanding breastfeeding behaviours and stimulate further research into evaluating the safety and scientific efficacy of these products in Ghana.

Fenugreek Stimulates the Expression of Genes Involved in Milk Synthesis and Milk Flow through Modulation of Insulin/GH/IGF-1 Axis and Oxytocin Secretion

We previously demonstrated galactagogue effect of fenugreek in a rat model of lactation challenge, foreshadowing its use in women's breastfeeding management. To assess longitudinal molecular mechanisms involved in milk synthesis/secretion in dams submitted to fenugreek supplementation, inguinal mammary, pituitary glands and plasma were isolated in forty-three rats nursing large 12 pups-litters and assigned to either a control (CTL) or a fenugreek-supplemented (FEN) diet during lactation. RT-PCR were performed at days 12 and 18 of lactation (L12 and L18) and the first day of involution (Inv1) to measure the relative expression of genes related to both milk synthesis and its regulation in the mammary gland and lactogenic hormones in the pituitary gland. Plasma hormone concentrations were measured by ELISA. FEN diet induced 2- to 3-times higher fold change in relative expression of several genes related to macronutrient synthesis (Fasn, Acaca, Fabp3, B4galt1, Lalba and Csn2) and energy metabolism (Cpt1a, Acads) and in IGF-1 receptor in mammary gland, mainly at L12. Pituitary oxytocin expression and plasma insulin concentration (+77.1%) were also significantly increased. Altogether, these findings suggest fenugreek might extend duration of peak milk synthesis through modulation of the insulin/GH/IGF-1 axis and increase milk ejection by activation of oxytocin secretion.

Enabling Breastfeeding to Support Lifelong Health for Mother and Child

The health benefits of breastfeeding are well documented, and more than 80% of US women initiate breastfeeding; however, mothers in the United States face substantial challenges in meeting their personal breastfeeding goals, with approximately 60% weaning earlier than they had intended. In addition, there are significant racial/ethnic inequities in infant-feeding behaviors, and these inequities are a major public health concern. Enabling women to meet their breastfeeding goals is a public health priority. Infant feeding should be addressed as a modifiable health behavior, rather than a lifestyle choice.

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.