By Arianna Cortesi, MD; Craig Schneider, MD; and Ted Wissink, MD
Dr. Schneider is Associate Professor of Family Medicine, Tufts University School of Medicine; and Director of Integrative Medicine, Department of Family Medicine, Maine Medical Center, Portland.
Dr. Wissink is Assistant Professor of Family Medicine, Tufts University School of Medicine; and Associate Director of Integrative Medicine, Department of Family Medicine, Maine Medical Center, Portland.
Dr. Cortesi is Integrative Medicine Fellow, Tufts University School of Medicine, Maine Medical Center, Portland.
Summary Points
- One of the most common reasons given for early discontinuation (prior to 6 months of age) of exclusive breastfeeding is perceived or actual reduction in breast milk supply. Therefore. many people who breastfeed look to herbal supplements for assistance.
- This review examines factors that may result in a reduction of breast milk supply as well as the available research surrounding food-based galactagogues thought to aid lactogenesis.
- A review of the available research shows a lack of high-quality evidence behind seven common food-based galactagogues.
SYNOPSIS: This literature review examines the research that has gone into nearly a dozen common galactagogues. An examination of the available randomized controlled trials and review papers reveals a lack of high-quality research but also offers recommendations to help breastfeeding parents.
Galactagogues are medications, herbs, supplements, or foods that are believed to help with breastfeeding initiation, maintenance, or supply. The American Academy of Pediatrics recommends breastfeeding exclusively for six months, then breastfeeding in addition to solid foods for at least one year or until weaning is mutually desired by parent and infant.
There are many improvements in health, both obvious and subtle, for the breastfeeding parent and baby. For the infant, studies show a reduced risk of obesity, reduced levels of allergies, improved immunity, and reduced rates of upper respiratory infections and otitis media, among many other benefits. For the breastfeeding parent, studies show reduced obesity, reduced risk for breast cancer later in life, and and a reduced risk of cardiovascular and autoimmune disease.1 Additionally, supply bottlenecks stemming from the COVID-19 pandemic and the closure of a large formula-production plant in February 2022 have made breastfeeding even more crucial.2
Since one of the most common reasons given for early discontinuation (prior to 6 months of age) of exclusive breastfeeding is perceived or actual reduction in breast milk supply, many people who breastfeed look to herbal supplements for help.1 Many parents, both historically and cross-culturally, also incorporate herbs or nutrients thought to help with breastfeeding into traditional postpartum foods and teas.3 In this sense, galactagogues and traditional postpartum herbs/foods may be thought of as plants that “act generally in relation to well-being of infant and mother … the galactogogue best understood as proxy for this broader purpose is often appreciated by women, if not by healthcare providers.”3
Most traditional galactagogues and postpartum foods have immune-inflammatory, antioxidant, antimicrobial, or neuroactive activities and have limited toxicity and/or a long history of safe use, regardless of laboratory data.3 Other points raised by ethnographers and botanists include the known transfer of flavor constituents from traditional herbs and foods into breast milk.3 This exposure to different flavors in utero and lactation is hypothesized to lead to greater acceptance of a variety of foods as infants transition to solids, which may have broader health benefits (such as greater tolerance of bitter plants that have specific medicinal/anti-infectious properties) and also from a cultural standpoint (reinforcing and fostering shared cultural identity through food, as well as the experience of community care the postpartum parent experiences).3
Importantly, in the United States, many parents turn to galactagogues when they perceive or experience low milk supply. Their hope and expectation is that their milk may “come in” sooner and/or their established milk supply may increase. However, milk production is extremely complex and depends on a cascade of hormones (affected by physical and emotional factors) as well as regular and thorough milk removal.
Lactogenesis I occurs during pregnancy as the mammary gland completes development under the influence of estrogen, progesterone, and prolactin.4 This can be inhibited by many maternal medical conditions, but perhaps most commonly, polycystic ovary syndrome and insulin resistance.1
Lactogenesis II begins after expulsion of the placenta, which causes a rapid drop in progesterone and estrogen, allowing a rise in oxytocin and prolactin.4 At this point, nipple stimulation (via pump or suckling or hand expression) triggers continued prolactin surges, which cause secretory activation of lactocytes.1 This process, often called “milk coming in,” typically takes two to seven days, and can be affected dramatically not only by maternal medical conditions, but also delivery complications, such as maternal hemorrhage, cesarean delivery, stress/pain, hypertensive disorders of pregnancy, prolonged labor, and, potentially, exposure to artificial oxytocin, although this is not well researched.4 Dopamine also can inhibit prolactin secretion.1
During secretory activation, emptying breasts frequently (at least eight to 10 times daily) is essential for establishing long-term milk supply by triggering activation of as many mature lactocytes as possible.4 Manual expression typically is more helpful for removal of colostrum in the first few days postpartum, as colostrum is higher in fat content and therefore thicker and more difficult to remove via non-physiologic suction.4 Once supply is established, the rate of milk synthesis primarily is controlled by negative feedback from full milk glands and ducts; if milk is not drained frequently, production can decline, and if milk expression is increased, secretion can increase. Low supply most often is related to suboptimal milk removal, either while establishing supply in the first weeks postpartum or later in lactation as parents return to work, infants sleep more, or as they start solids. Because of the importance of frequent emptying in establishing and maintaining supply, it is essential for new parents to understand how to tell if an infant is transferring well vs. poorly at the breast and to understand the supply/demand mechanism of the process.4
Unfortunately, many parents do not receive adequate support in learning these skills and turn instead to galactagogues and supplementation with formula when, in fact, the best remedy for low supply and maintenance of exclusive breastfeeding typically is increased frequency of emptying the breasts.1 When parents supplement with donor milk or formula without giving the breasts extra stimulation to trigger more supply, supply can continue to wane.1 The practice recommendations for low supply or perceived low supply as established by the Academy of Breastfeeding Medicine are as follows:
- Confirm that milk production is actually low — such as when infant weight gain is inadequate or supplementation is being used — and ensure that the infant has no contributory conditions.
- Evaluate for medical causes of low supply, and treat them if they are found.
- Assess and increase frequency and efficiency of milk removal — either by optimizing latch or adding pumping sessions. Recommend eight to 10 emptyings/day with no more than one four-hour gap overnight; aim for at least one emptying in the 1-4 a.m. period (maximum prolactin production).
Regarding galactagogues, there are two categories: pharmaceutical (dopamine antagonists, primarily domperidone, and metoclopramide) and herbal or food-based. Data on the efficacy of pharmaceuticals are limited, but some studies indicate benefits, particularly in “bringing milk in,” or lactogenesis II, more rapidly after delivery.1 The mechanism of action is theorized to be an increase in prolactin levels by suppression of dopamine release.1 However, once supply is established, there is no direct link between prolactin level (stimulated or baseline) and quantity of milk synthesized.4There also are safety concerns with the use of these agents; domperidone is linked with increased risk for ventricular arrhythmias and sudden cardiac death, and metoclopramide has been linked to higher rates of perinatal mental health concerns, akathisia, and tardive dyskinesia.1,5 Domperidone is not available for use in the United States due to these concerns. It is worth noting that, in subgroup analysis for sudden cardiac death with domperidone treatment, women had no increased risk, and people younger than 60 years of age also had no increased risk, so some providers will feel comfortable making this recommendation after screening for a history of cardiac disease and concurrent QTc-prolonging medications.5 The evidence behind metoclopramide is more scant, especially in recent studies, but some older studies show improvement in milk yield with at least 30-45mg daily (typically divided three or four times per day).1
Herbal galactagogues are used more commonly than pharmaceuticals and come in the form of capsules, tinctures, teas or tisanes, or as traditional foods prepared for the postpartum period in many cultures.1 Unfortunately, when taken as supplements, they face the same challenges that many supplements do regarding standardization of amount, ingredients, and contaminants.1 There are very few well-conducted randomized controlled trials in lactating parents, and most data are flawed either by low study numbers, variable inclusion criteria (e.g., term vs. preterm neonates), the use of combination herbal products, variable dosing or type of product administered, or highly variable methods of measuring outcome (e.g., infant weight, amount of formula supplementation, or volume of expressed breastmilk).
Additionally, mechanisms of action largely are unknown in vivo, although some have in vitro or animal data. We conducted a PubMed search for the 15 most commonly cited herbs and foods that have been described as helping with milk production. We looked at randomized controlled trials as well as review papers. Ultimately, we narrowed our list to the most commonly used/cited herbs in the lactation community: fenugreek, fennel, shatavari, moringa, ginger, goat’s rue, and milk thistle. The findings are summarized in Table 1.
Table 1. A Review of the Evidences Surrounding Common Food-Based Galactagogues1,3-10 | |||||
| Galactagogue | Theoretical Mechanism of Action | Dose/Duration | Efficacy | Data Quality | Risks/Concerns |
|
Fenugreek |
Acts on sweat glands to increase excretion |
570-600 mg PO TID for 1-3 weeks; most studies started immediately postpartum |
May increase milk secretion, although there is inconsistent data; with fennel, may improve infant weight |
Low-quality studies, low certainty |
|
|
Milk thistle |
Stimulates prolactin |
200-400 mg/day of micronized silymarin; tea (1 tsp crushed seeds in 8 oz water for 10 min, 2-3 cups/day). Study was for 2 months |
May increase milk secretion in the short term; no difference at 4 weeks; one study showed an increase after two months |
One study in lactating women, very low certainty |
|
|
Fennel |
Stimulates prolactin and potentially assists milk ejection reflex |
0.1-0.6 mL oil |
Inconclusive; with fenugreek, may increase infant weight |
Low certainty |
|
|
Ginger |
Unknown |
500 mg daily for 7 days |
May increase milk secretion either alone or in combination with fenugreek and turmeric; one study showed improvement in milk volume produced on Day 3 but no difference on Day 7 |
Low certainty |
|
|
Shatavari |
Stimulates prolactin |
Root extract 60 mg/kg body weight per day; 4-week duration |
Inconsistent results; one study suggested it may decrease volume of supplemental feeding; no difference in supplemental feeds or weight gain; one small study showed increase in prolactin level and infant weight |
Very low certainty |
|
|
Moringa |
Stimulates prolactin |
250-350 mg capsules BID, treated for 8 days starting three days pospartum |
Tentatively promising; may increase prolactin level, infant weight, may increase volume, noninferior to domperidone in one study; one study showed no significant difference in volume produced |
Very low certainty |
|
|
Goat's rue |
Stimulates mammary growth and aids in insulin sensitivity |
1-2 mL tincture BID-TID |
Inconclusive |
|
|
|
PO: per os; TID: three times daily: BID: twice daily | |||||
DISCUSSION
Herbal galactagogues are very commonly used in the postpartum period to assist with lactogenesis II (milk coming in) as well as with perceived or actual insufficient supply. We assessed the available data regarding efficacy of common herbal galactagogues. Overall, the quality of data is all of low or very low certainty, making it difficult for clinicians and new parents to choose an evidence-based treatment plan. However, many of these herbs have been used for hundreds or even thousands of years (e.g., fennel), without obvious safety concerns when used as foods or teas.3,6,12
The quality of the product used is important; as with all herbal products, there are concerns of heavy metal contamination in particular, and some studies have found that heavy metals and pesticides are present in herbal supplements on the U.S. market as well as in some traditional Chinese herbal formulations.6,12 Therefore, our recommendation is that, in any consultation, clinicians should assist parents with access to resources that conduct third-party contamination and active ingredient testing to confirm that their specific supplement or herbal product is safe. Additionally, if the clinician does not have expertise in breastfeeding medicine, it is essential to promptly refer parents to a lactation consultant or another trained provider, such as a breastfeeding medicine physician, for a complete evaluation to optimize frequency/efficacy of milk removal and to address any medical concerns, such as hypothyroidism, retained placental fragments, or other factors that may inhibit lactation.
The role for peripartum and postpartum herbal supplementation has a rich cultural history, and many herbs are safe, although with minimal data to support efficacy. In this light, while it is reasonable to avoid recommending any specific herbal remedies for breastfeeding, it is important to use shared decision-making to help patients understand the limitations of the data as well as the safety profile of most herbs to assist them with the information they need to reach their own decisions in their specific cultural and social context.
REFERENCES
- Brodribb W. ABM Clinical Protocol #9: Use of galactogogues in initiating or augmenting maternal milk production, second revision 2018. Breastfeed Med 2018;13:307-314.
- Pearson C. What parents need to know about the formula shortage. The New York Times. Published May 13, 2022. https://www.nytimes.com/article/formula-shortage-help.html
- Sibeko L, Johns T. Global survey of medicinal plants during lactation and postpartum recovery: Evolutionary perspectives and contemporary health implications. J Ethnopharmacol 2021;270:113812.
- Balkam, JJ. Galactagogues and lactation: Considerations for counseling breastfeeding mothers. MCN Am J Matern Child Nurs 2022;47:130-137.
- Bozzo P, Koren G, Ito S. Health Canada advisory on domperidone should I avoid prescribing domperidone to women to increase milk production [corrected]? Can Fam Physician 2012;58:952-953. [Erratum in Can Fam Physician 2012;58:1085].
- Bazzano AN, Hofer R, Thibeau S, et al. A review of herbal and pharmaceutical galactagogues for breast-feeding. Ochsner J 2016;16:511-524.
- Foong SC, Tan ML, Foong WC, et al. Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non-hospitalised term infants. Cochrane Database Syst Rev 2020;5:CD011505.
- Khan TM, Wu DB, Dolzhenko AV. Effectiveness of fenugreek as a galactagogue: A network meta-analysis. Phytother Res 2018;32:402-412.
- Paritakul P, Ruangrongmorakot K, Laosooksathit W, et al. The effect of ginger on breast milk volume in the early postpartum period: A randomized, double-blind controlled trial. Breastfeed Med 2016;11:361-365.
- Sharma S, Ramji S, Kumari S, Bapna JS. Randomized controlled trial of Asparagus racemosus (Shatavari) as a lactogogue in lactational inadequacy. Indian Pediatr 1996;33:675-677.
- Kwan SH, Abdul-Rahman PS. Clinical study on plant galactagogue worldwide in promoting women’s lactation: A scoping review. Plant Foods Hum Nutr 2021;76:257-269.
- Budzynska K, Gardner ZE, Low Dog T, Gardiner P. Complementary, holistic, and integrative medicine: Advice for clinicians on herbs and breastfeeding. Pediatr Rev 2013;34:343-353.
This is a review of the research that has gone into nearly a dozen common galactagogues. An examination of the available randomized, controlled trials and review papers reveals a lack of high-quality research but also offers recommendations to help breastfeeding parents.
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