Moringa oleifera (Malunggay) as a Galactagogue for Breastfeeding Mothers: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

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King, KS et al
lloringa oleifera (Malunggay) as a Galactagogue for
Breastfeeding Mothers: A Systematic Review and
lleta-Analysis of Randomized Controlled Trials
Iacelie S. King.\ID*,Peter Francis N. Raguindin, MD*, Leonila F. Dans, MDo*
\ bstract
Beckground. \{oringa oleifera (Malunggay) capsules
- j'.; reen prescribed for years by many physicians in the
::,-rrrrtion of breastfeeding. Its efficacy has not been well
:s:aL'lished due to few, small randomized controlled trials.
Objectives. To perform a meta-analysis of the available
data in the medical literature, assessing the effect of intake
oi \loringa (malunggay) by postpartum women, on breast
milk volume and infant's growth.
Data sources: PubMed, Cochrane Controlled Trials Meta-
Register, electronic databases of published, unpublished
and non-english language papers; conference proceedings,
reference lists, and trial authors.
Selection Criteria. Randomized controlled trials (RCTs)
eramining the effect of intake of Moringa on breastmilk
production of postpartum breastfeeding women, were eli-
gible for inclusion.
Data Collection. Absolute and relative changes from
baseline u'ere calculated for individual studies and pooled
using a randor.r-i eftcts rrodel.
\Iain Results. Fii e RCTs including -r66 participanrs rret
il-;: i:.'-t.s:o: .-ri:e:r: Oi the tr'.liCtrntiS rer ieri ed. onlr
;::-'-:..1- .r. . .--ll.; S.. .,.:: : >.-:...::.'...r .:::'.::l;fttt ill-
-::j>a :- ,. '.t. i:.- ::3-::::,3:li -,r, lil-. ]1\-:.:l{: C:ilSL.]eS trn dar
-:. i ":; - T:.; .:-.-'. Sl> rrl !otrled dat: der:t.'rnstrated a
.t=tist:.'-r, '. rt-::'l-:-:,-a;:: :e,:tire lnclease on dar -1 0f],1.09
r1l re5:,, CI f-O f:. 19.,r-i pT:.o6t: dal-< oi ji.-8 61 (9-590
CI l-+.1+. -19.-11 p<.000{,)1t and on da1 7 of 123.87 ml
(95o0 CI 89.-+8. 158.26 p:.32) milk rolume u,ith moringa
capsr-r1es treatrnent cornpared to placebo. Two RCTs re-
ported an increase in infants' weight as an outcome with
the use of morin_qa capsules. No adverse events were ob-
serred in anv of the trials.
Conclusion. Er idence from Randomized Controlled Tri-
-'..s:r.-\e ihat \loringa results in an increase in breast milk
,. - __.:.1:a ._O:ln:red tt plaCebO.
oleit-era. \lalunggal'.
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BACKGROUND
Description of the condition
The most recent National Demographic
and Health Survey 2003 of the National Statis-
tics Office showed that of the 7 million children
below 5 years old in the Philippines, only 87%
were breastfed. This includes infants whose
breastfeeding lasted for only one hour, one day
or one week. Nearly 3.4 million children (49%)
were given complementary feeding within 3
days after birth. Barely 6% were exclusively
breastfed. Although B0% of children started
breastfeeding within 24 hours from birth, exclu-
sive breastfeeding only lasted for an average of
24 days. Among mothers who did not breastfeed
their children, 31o reported that they did not
have enou-qh milk.(l) Physicians use several
methods to promote breastfeeding; these include
matelxal edr"rcation, non-separation policy, and
rrnplorin,e the help of a lactation specialist. To
augment the problem in the adequacy of milk
volume, clinicians often use galactagogues.
Description of the intervention
Galactagogues are medications or sub-
stances believed to assist initiation, maintenance
or augmentation of maternal milk production.(2)
Common galactagogues include domperidone
and metoclopramide. Both are deemed to inter-
act with the dopaminergic system which in turn
promotes the release of prolactin. There are sev-
eral other herbal plants that are said to have lac-
togenic effects including anise seeds, Bermuda
grass, fennel seeds and quinoa.(16)
In the Philippines, Moringa leaves
gro\\.n in backyards. usually prepared as a vege-
table inqredient in chicken soup, have been used
br nrothers to enhance milk production.(3,4) It
has been encapsulated. marketed and sold com-
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The Philippine Journal of Pediatrics
Vol.61 No.2 December 2013
Kirrg. KS et al
mercially to help increase breast milk
ing mothers. lactat-
How the intervention might work
Lactogenesis is initiated in the postpar-
tum period by a decrease in plasma progester-
one, with coffesponding increase of serum
prolactin 1eve1.(5) According to Hans Selye,
each baby's suckling episode is associated with a
rise in plasma prolactin. Thus frequent nursing
is required to maintain high plasma prolactin
level. However, if standard physiologic meas-
ures (proper attachment and frequent nursing)
are only parttally effective, drugs like reserpine,
metoclopromide, domperidone, and thyrotropin
releasing hormone (TRH) can be utilized to
stimulate prolactin production. (7)
In the Philippines moringa leaves have
been used to enhance milk production with un-
clear mechanism of action. Almirante and Lim
(6) proposed a mechanism for its lactogenic ef-
fects. The study showed that there was a greater
increase in maternal prolactin levels among
breastfeeding mothers who took the leaves.
Why it is important to do this review
Quisumbing l97B first noted the use of
moringa leaves as a galactagogue. This lactation
-enhancing effect of moringa leaves was demon-
strated in a local study done by Almirante and
Lim (1996), wherein moringa leaves in the form
of Natalac capsules were given to pregnant term
Filipino women immediately after birth. The
study showed significantly higher prolactin lev-
els among mothers taking Natalac capsules ac-
"-ompanied by significant weight gain among
their babies. A follow up study done by the
same authors among hypertensive women moth-
ers showed the same result.
In a randomized controlled trial done by
Estrella et. al.(14) the administration of Moringa
;apsules showed an increase in milk production
rn postpartum day 4 to 5 among mothers who
ielivered preterm infants, with no reported side
:I-tects. Another study by Balahibo et at- (12)
:ioted that among breastfed newborns, there was
a significant incrals.' :: ""i3.:.:
newborns u-hose t.t],-'ltiti '.'" Jlr' length of
nroringa
capsules from binh i,-' : rr.rl-:
noted that lactation st5.::1.=:: '' l lr-''. -'d ln
those taking moringa capsu":s :.:::^. I ::r:tl:
study period.
OBJECTIVES
This study aims to Peri.::: : -: -'-
analysis of the available data in thc ::e; :. :-
erature, assessing the effect of intake .': \1 : : - ti
by postpartum women, on volume of n::"r'. :: *
duction, and infant weight garn.
METHODS
Criteria for considering studies for this
review
Types of studies
A11 randomized controiled trials comparing Mor-
inga versus placebo or any other galactagogues
are eligible for inclusion in the review. Search
was not limited by date, language or publication
status.
Types of participants
Post-parlum mothers who have taken raw or
pharmaceuticaliy compounded drug with Mor-
inga oleifera as active ingredient were included.
Mothers who had taken Moringa prior to delir--
ery or as prophylaxis were excluded from the
study.
Types of interventions
Intervention in the included studv should use
Moringa oleifera either as raw o:' pharmaceuti-
cally compounded d*g. We cxcluded studies
that used Moringa for an.v other purpose othe:
than as a galactagogue. Studies u here il'lt-rt:3r:
took Moringa for re-lactation or to prlor lr-r 'j:-
livery were also excluded. Controi rarieb-3 :-::
to be a placebo tablet of similar phrsic:. ;:i::--
teristic as that of the studv drug tlr rr." ::::: '-
cologic agent deemed to har.' g:-.:::' rr;
properties.
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The Philippine Journal of pediatrics
Vol. 6l No.2 December 2013
Types of outcome measures
Primary outcomes
The primary outcome was measured
both in-vitro and in-vivo. In-vitro r,easllrernenr
involved measuring the volume of breastmilk in
milliliters (mL) or cubic centimerers rcc, ob-
tained through expression br eitlier han,J or ma-
chine. In-vivo measure,r-,.ni * as rhe adequacy
of milk producrion as er i,Jencerj br- i.nfant
weight gain. This t-rUtCorre \\ as nrearu.Ld using
percentage ri eisht ga;ir I :' r.
secottdot'.' | ):i i( r, tllg _:
.\:lorher t-rutcoflte that was determined
u as the ler el ol maternal prolactin production
nreasured in million International Units per liter
trnlU L t. Ler,'els of prolactin are said to be re_
lated to maternal breastmilk production. Ad_
\ erse drug events related to use of Moringa
\\ ere also noted and documented.
Search methods for identification of studies
We searched the following electronic
databases using the search terms already de_
scribed in Appendix l: Moringa oleifera, Mor_
inga pterygosperma, Moringa , Malungga,
Drumstick tree, Horseradish tree and Ben oil
tree for the intervention. These search terms
were combined with the search terms: breast_
feeding, breastmilk and lactation.
Electronic searches
The following electronic databases were
searched with uniform search strategy.
MEDLINE
CENTRAL
EMBASE
Controlled Trials MetaRegister
HERDIN
Searching other resources
Citations and reference lists of identified
articles were examined for additional relevant
studies. Conference proceeding and local jour_
nals were hand searched for relevant resear.h.r.
Experts and researchers were queried for ongo_
rng andlor unpublished trials.
King, KS er C
DATA COLLECTION AND ANALYSIS
Selection of studies
Two authors independently examined L1E
title, abstracts , and keywords of citations tiom
electronic databases for relevance and sub*-
quently eligibility. The full text of all reler a::m
records were obtained and independ ently a-i_
sessed as to whether each met the predefined
inclusion criterra. The authors used a form for
standardization of appraisal methods. Disagree-
ments were discussed and if consensus was not
reached, it was adjudicated upon by the third
author. Excluded studies and the reason for ex-
clusion were noted and tabulated.
Data extraction and management
The primary and secondary outcomes
were all of continuous variables. The arithmetic
means and standard deviations for the two
groups were determined from the study and
compared. The unit of measurement were ascer-
tained as uniform to ensure consistency.
Assessment of risk of bias in included studies
Methodological quality was assessed in_
dependently by two review authors using the
guidelines in the Cochrane handbook and was
assessed for overall quality of evidence using
the GRADE approach. The parameters to be
used in assessing the risk of bias will included
random allocation, concealment allocation.
blinding and reporting biases.
Measures of treatment effect
The volume of breastmilk was measured
using cubic centimeter (cc) or milliliter (mL).
Infant's percent weight gain was expressed in
percentage. The level of maternal prolactin was
measured in million International units per liter
(mfU/L). A weighted mean difference between
treatment and control groups was determined
using RevMan 5.1. Analysis was based on mean
difference using random effects model.
Dealing with missing data
The authors contacted the original inves-
36

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'i\illll*rriltr, ,rr,, \ ,'. I DeCembef 2013
rlililnun. -i :or the missing data in the study. Rea-
h#rlrlnl '" : omission will also be noted. In cases
wrlrrrilu-: . I alue in the study interpretation is miss-
urrril[ - s sroup will derive the said data and the
,ulrrriJ, -* ,,"i be used to complete the analysis.
lDrull * nthesis
t-)nl1l studies with comparable interven-
lllr{iirr -u-:lulations and outcomes were pooled and
irillflilriiiiL :':j. The investigators used RevMan 5.1
,rilililrn :;:iation of mean difference of each out-
lil:un " ":d subsequently compared, pooled and
..llnrllr-r :.C studies of comparable interventions
,illllllr,il,t t, lulation. Inverse variance was computed
r i- -- red effects method as determined by
'iil,- ',1:n 5.1 and reported accordingly.
rrurl'group analysis and investigation of
Mfie il'ogeneity
-\ table of study characteristics u/as com-
q :' ; I br the investigators and \\,as used in as-
uur - - the clinical and methodical hetero_eenein-
",-:i study. Statistical heterogeneity was as-
iuri .,- I using Pearson Chi Squared test as deter-
''-ibr.RevMan5.
fII[ :T LTS
lnrr+c ription of studies
Xc.,u/r-s o.f the search
-\ total of 32 titles and abstracts were re-
""" : - - through searching databases and refer-
r'- . - ::acking. We obtained the full text of six
,. * - -'i among which one trial was ineligible due
-:: of intervention prior to delivery (Figure
l:e t-inal trial sample consisted of five ran-
- * zed trials for the review. The details of in-
" -.J trials are reported in 'Characteristics of
-- -;ed studies'. The reasons for excluding tri-
.r " ::e stated in 'Characteristics of excluded
,lIL_ i>
King, KS et al
Fisure 1, Fltrs chan ..1'S.'1.'c:;: S:-;:.-.
Included studies
Of the fir'e included trials. four trials
were done in tertiary hospitals(2,12.13.1-+; u hile
one was done in the community setting.(6) Four
trials compared Moringa capsules against pla-
cebo(6,12,13,14) while one trial compared Mor-
inga capsules as well as other galactagogues like
domperidone and metoclopromide against plain
breastfeeding(2) in a randomized manner. A to-
tal of 366 postpartum mothers were recruited
across all trials. Among the participants, 108 of
them were mothers of preterm infants while the
rest of them were mothers of term infants not
suffering from any illness at birth. An informed
consent was obtained from all participants in
four trtals(2,6,13,14) but it was not explicitly
stated in one trial(L2). Reporting of inclusion
and exclusion criteria was similar across trials.
Of the five pooled trials comparing the
efficacy of Moringa as a galactagogue for
breastfeeding mothers, three trtals(2,L3,14)
measured milk volume, two trials(6,12) meas-
ured infant weight, two trrals(2,6) quantified
maternal prolactin level, and all trials reported
adverse outcomes.
31
Total Number oiRe.-..r.1s I;::ii:led: 3l
Cochrane LiL,::r.. ,
HERDI\ \eO\ r -1',,
MetaRegister of Controiled T:i.:'is , ', t
Number of Records
Excluded: 26
Not related to lactation
Number of Articles Assessed for Eligibility
Number of Articles
Excluded: 1
Capsules taken prior to
Number of Articles included
nves-

Eri !\lrml:,: i]r"c J,, r.r r nal of Pediatrics
r-! \ I Dgcember2013 King, KS et al
\.i ik \olume measurement varied from
*; -: :..i-paftum to 4 months, as well as infant
- :-. :.rken tiom birth to 4 months and mater-
:,.:-plrtum to 4 months. No adverse effects
srr' rote d in four trials.(2,6,13,14)
E.rc'lttcled stadies
One study was excluded because Mor-
rnga capsules were taken by mothers prior to
delivery.(10)
Risk of bias in included studies
A I I o cutio n (s ele ctio n bius)
In only two of the five trials, \\,as ran-
domrzation done using a controlled block desiglr
(2) and table of random numbers (14). Ran-
domrzation details were not specified in two ol
the remaining 3 trials(6,12), while in the last
trral, randomization was done by the researcher
with high risk for bias.(13) Allocation in 3 of
the five trials had low risk for bias with treat-
ment assignment concealed using opaque sealed
envelopes, identical containers which were
coded at the source.(6,1r3,I4) The remaining 2
trials did not specif.v how allocation conceal-
ment was done.{2,12;
Blinding (performance bius und detection
bius) Three of the four trials ensured blinding
of participants and personnel (6,12,i4) while in
the remaining one trial only the participants
\ /ere blinded.(13) One trial did not specifiy any
biinding done.(2) ln all trials. blinded individual
assessors were used. For the assessment of milk
volume, a standardtzed, calibrated breast pump
and container were used. Milk volume was ei-
ther recorded by the subjects themselves or by
:he study personnel. Prolactin level was meas-
..red using the ELISA technique while a check-
irs: of adverse symptoms was provided for the
su:-iects. Infants'weight gains were measured by
'r-rnded doctorst'students but the method was not
stated in .-rne trial.(6)
Incomplete outcome data (uttrition bius)
The intention-to-treat principle was not
mentioned in any of the pooled trials. A11 trials
reported number of dropouts and withdrawals
comectly except one trial which did not assess
this outcome.(12)
Selective reporting (reporting bius)
All pre-specified outcomes like milk vol-
ume, maternal serum prolactin level, infant's
weight and adverse effects were reporled in all
pooled trials.
Other potentiul sources of bius
Eighty percent of the triais were per-
formed before the year 2005 and ZAoh before the
year 2000. The number of patients per trial
ranged between 40 tbr the smallest(2; and 1 16
patients for the largest.(6) Only one tnal enrolied
rnore than 100 patients (61 and only one trial in-
cluded information on sample size calculations.
( 12)
Effects of interventions
Milk Volume
A11 three trials noted milk volume on day
3 postpartum with intake of Moringa capsules
starting on the same day(2,13,14); two trials re-
ported milk volume on day 4 a*d 5 (13, 74); and
two trials on day. 7(2,13) 1 trial each reported
milk volume on day 10(13) and day U.(2) The
comparison regarding the outcome milk volume
enrolled atotal af 171 participants flor day 3, 150
participants each for day 4 and 5, and IA2 par-
ticipants for da1. 7 in the Moringa vs placebo
group. The pooled analysis for du)' 3 showed
heterogeneity of effects (Chi2 : 4.59 df:Z 12 :
56% p:0.1) and faiied to show a significant as-
sociation of Moringa capsules to increase milk
volume against placebo (pooled ratio of the
means of 13.58 (95% CI -1 .67,28.83). On days
4 and 5, pooled analysis show-ed heterogeneity
of effects (cht2: 3.5 df :7 12: 7I% p:0.06,
chtT: 33.88 df :1 12: 97% p<.00001 respec-
tively), there was significant association of
38
F

r,, I'hilippine Journal of pediatrics
r | \o. 2 Decemtrer 2013 King, KS et al
:. rga capsules with increase milk volume
.-- nsr placebo (day 4 23.09 {95% CI 16.g5.
- ' :-: l: day5 31.78 {95% CI 24.24,39321 ). On
-",., -. pooled analysis showed homoeeneitr .i
, --'--tS (chi2:0.98 dF1 p:0.32) and sienitlcant
- - :3ase in mean difference of rnilk ,-olti,re ii ith
:'inga capsules against placebo at 123.g7 ml
"- ertraction (95% CI g9.4g , 15g.26). Fig.2
kpcilmraul ftntnl &i$rr 0ilfcrtn{r
,l'r;l [{tan 5D Totil &lean i[ Totll l{crght l!,iired,$5$ll
ilcan Dilftnnn
ll', Fixrd, 95ii il
r*[ 6t !l jj it *j i /$ jj ifr it ii 6f, 5t i]t ?; r*6J4i
.;i f., ;r it ;. .:i t ..i,. ;: ii i .ii j; itr il ,i[ li
51 il 100.0\ lil.$i i8!,{t, 1t8,ifi1
i;vtui: tuiillci iei+in *ttrmitn,r;
- -.:e l. Forest plot of comparison: I Moringa vs placebo, outcome:
..:le of Breastmilk Day 7 "Infants'Weight
Two trials(6,12) studied the efficacy of
moringa capsules versus placebo as a galac_
tagogue by measuring increase in infants,
weight. One trial(6) measured the weight at
birth, at 2 weeks, at 1 month and, at 4 monlths of
age which included 1 1 6 participants in the mor-
irqu versus placebo group. One trial(|2) noted
infants' weight at 2 weeks, 4 weeks, 6 weeks and
8 weeks of age in 30 participants. percentage
weight gain was noted in the moringa group for
both trials. (Table 2)
Table l. Percentase \\'eisht Gain
+
Froluctin Level
Two trials were carried out to assess the
-:':icacy of moringa capsules versus placebo in
r' increase maternal serum prolactinlevel .(2,6)
':re trial(6) reported on maternar serum prolac-
:r ievel on 1 16 patients, 6 hours imm.diatery
- .'stpartum (first .extraction), 2nd day postpar_
"''r (2nd extraction) and 4 months postpartum
': rd extraction). The median prolactin rwer on
-e first extraction was 4B0B mIU/L in patients
", ho took moringa capsules compared to 5134
^'IIJIL in patients who took pracebo. prolactin
-.'r els were higher in the treatment group on the
-:rd and 3rd extraction and was statistically sig_
'.:t-rcant yielding a ratio of the medians or t-ss+.q
)5% CI 1601.8, 2L6B) and t83B (g5% CI
. it7 3.04, 2602.96), respectively. One trial (2)
,:ported on the prolactin levels on day 3 postpar_
:Lrm, day 7 postpartum and day 14 posipartum
r,,rt did not show any significant difference
:mong all 3 groups. The comparison included a
:.-,tal of 40 patients. (Table 1)
Trllr. L serunt Prolactin Level
5t udr
Treatment Placebo
Mean,
mlUiL
(n) SD Mean,
mIU/L (n) SD
8.4 5134.0
(58) 2304.4
Dar 3398.0
(,s 8) 1939.5
Day 3Co 2001 :ll 9
l,tr 2189.8
Day 7Co 2002 :0.1 E. -
(lo) l!nri.0
Day
14 Co2002 1229.2
( l0) 1468.6
4 mos Almirante
1996 2389.0
(s8) t019.7 504.1r-sSr
Studr
-\loringa Placebo
\1ean.
o,
/o SD \ Iean.
o/
/o SD
BWto 1
week Almirante
1996 r.300 13.27 0.029 2.84
BWto2
weeks
Almirante
1996
Balahibo
2002
7.944
27.35
15.649 5.506
18.35
4.3261
BWto4
weeks
Almirante
1996
Balahibo
2002
30.31
72.22
22.863
nla
17.04
44.s
23.04
nla
BWto6
weeks Balahibo
2002 120.94 nla 75.36 nla
BWto8
weeks Balahibo
2002 156.46 n/a 110.41 nJa
BW to l6
weeks Almirante
1996 123.60 6l .51 74.410 3s.726
39

The Philippine Journal of Pediatrics
Vol.61 No.2 December 2013 King, KS et ul
Adverse Efficts
Only four trtals(2,6,13,14) reported on
adverse effects in the treatment group. All trials
reported no adverse effects. However, in 2 trials
(6,14) the method of reporting adverse effects
was not stated. In the remaining two trials (1.13 r
a checklist was provided to the participants.
DISCUSSION
Summary of main results
Galactagogues are otten presc:-ibed xtr
breastfeeding mothers to increase the .tfltoilrx[ t-rf
breast milk production. \\-e rer ieu ed elllcacr of
morin_ea capsules as a galactagtrgue br compar-
ing outcontes such as milk rolume. maternal se-
rum prolactin lerel. and intants'u'eight in breast-
t'eeding mothers.
Three randomized controlled trials
( l. I 3. I -1 t reported on increased milk volume
u"ith the use of moringa capsules. The data pre-
sented in this review demonstrate a significant
increasing trend in the volume of milk starting
on day 4,5, and 7. Pooled trials did not show
any significant increase of milk volume on day 3
postpartum. This could be attributed to inade-
quate window of observation from initiation of
therapy. Although pooled analysis both showed
heterogeneity for day 4 and 5, it is noteworthy
that confidence interval of both days are statisti-
cally significant favoring the association of in-
take of Moringa capsules with increase in milk
volume.The quality of reporting of the milk vol-
ume trials showed some methodological defi-
ciencies and had small sample size of less than
100. None mentioned an intention to treat analy-
sis. Methodological quality was moderate in one
trial where the method of random sequence, con-
cealment of random allocation, double blinding
and number of dropouts were reported.(1a) The
two remaining trials showed methodological de-
ficiencies. One trial had high risk of randomiza-
tion bias and single blinding (13) while the re-
maining trial did not state allocation and blind-
ing procedure.
Increased prolactin production is the pre-
vailing theory on how Moringa produces its
lactogenic effects. Two randomized controlled
trials (2,6) reported on increase in maternal se-
rum prolactin level with the use of morin ga cap-
sules. However, both trials reported measure-
ment of prolactin level on different times, such
that no pooling of data cannot be done for com-
parison. Moreover, both studies showed con-
t)icting results. One trial(6) stated that there is
significant increase in maternal serum prolactin
ier el ri ith the use of moringa capsules while
antrther trial(2) stated otherwise. However, both
trials shou'ed methodological deficiencies. Both
trials did not specifl,- method of randomtzation.
In one trial. allocation concealment and double
blinding \\'ere done(6) and in the remaining tnal,
no allocation concealment and blinding were
stated.(2) Both however, noted blinding of as-
sessors by using the ELISA technique to meas-
ure maternal serum prolactin levels. Reporting
of withdrawals was noted in both trials. One
trtalhad a small sample size of 40.(2)
Two randomized controlled trials(6,12)
reported an increase in infants'weight as an out-
come with the use of moringa capsules. Both
trials had moderate methodological quality. Ex-
cept for reporting of double-blinding, none of
the trials properly reported the requested quality
criteria. Although percentage weight gain was
noted in both trials; no pooled analysis was
available for comparison. In one study(12) stan-
dard deviation was not specified, such that no
confidence interval could be derived. Taken sin-
gly, both trials reported increase in percentage
weight gatn with moringa capsules compared to
placebo. However, with no pooled analysis
available, it is unverifiable to report as such.
Overall, evidence from five small RCTs
unanimously concluded that Moringa produces
an increase in breast milk volume compared to
placebo.
Overall completeness and applicability of
evidence
The evidence provided by the review
appears to be widely applicable. Moringa
leaves are easily accessible in the Philippines as
it is found in many backyards. It is commer-
40

The Phitippine Journal of Pediatrics
Vol.61 No.2 December 2013 King, KS et al
cially available in capsule form. Outcomes such
as milk volume, prolactin level and infants'
weight are also measurable in our setting. As a
galactagogue, it is also well received by Philip-
pine medical societies, in its efforts at promotes
breastfeeding.
Quality of the evidence
Many important aspects of morin ga cap-
sules as a galactagogue cannot be addressed with
the current evidence. It would be interesting, for
example, to know whether differential drug effi-
cacy exits in term and preterm infants, primigra-
vid and multigravid mothers. Such subgroup
analyses, however, need adequate power or spe-
cific research questions and can not be an-
swered by this meta-analysis.
Potential biases in the revierv process
Most included trials are of small size and
therefore prone to effect overestimation due to
publication bias. Since the number of trials per
comparison was usually very limited, formal as-
sessment of publication bias was was not possi-
ble.
AUTHORS' CONCLUSIONS
Implicutions for practice
Moringa is commonly used in the Philip-
pines as a galactagogue to help breastfeeding
mothers increase milk production. This study has
proven its efficacy in increasing milk volume.
This conclusion is based on small trials with lim-
ited methodological quality compromising the
robustness of its quality. Nevertheless, it is im-
portant to recognrze that all studies favor the ex-
perimental (Moringa) group over the placebo
group. More pharmacodynamic studies need to
be done and other theories need to be explored to
provide information on the mechanism of its lac-
togenic effects. Available data on this is also
based on small trials with limited quality of
methodology.
Moringa is safe with minimal to no ad-
\ erse effects as reported by all five studies.
Implicutions for reseurch
Further studies should provide sufficient
transparent reporting of allocation, randomtza-
tion. and blinding. Follow up duration should be
adequate and studies should also use uniform
endpoint reporting of outcomes. In addition,
\lrrringa can be compared with other galac-
taStrSucs using a ran-qe of doses. Other surrogate
outctril'r3S ,--.tr L'e inr estigated such as decreased
incide:rce r.i lc.te gastroenteritis and respiratory
inti.'tit':S"
DECLAR{TIO\ OF I\TEREST
The ::i:,lrS r;\ 3 rtr attlliations with any
d*g ctrll-tp.litt35. T::s :e.elr--h uas not funded
1,1 an1 rns:r: ::ron. Tlr-e g-illtrrs rre members of a
pediatncs ,Jeptarrmenl i:J: :i , ke,. plarer in the
promoti on of brea>tteeCr n g
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