Selection and Use of Galactogogues

Abstract

Breastfeeding mothers are often are concerned about an inadequate quantity of breast milk, designated as insufficient milk supply. Many breastfeeding mothers will attempt to increase the quantity of breast milk production by taking prescription drugs and/or herbs and foods called galactogogues. Galactogogues are defined simply as substances that promote lactation. The most common prescription galactogogues are domperidone, metoclopramide, metformin, and oxytocin. Many common herbals and foods have been traditionally used as galactogogues. These galactogogues will be reviewed; this information will allow health care professionals in all settings to provide consultative services to breastfeeding mothers. Breastfeeding mothers and supporters will find the information useful to determine if galactogogues are necessary, and if so, which galactogogues are appropriate for use. Treatment guidelines including benefits, doses, actions, and cautions are discussed.

Full text

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ICAN: Infant, Child, & Adolescent Nutrition August 2015
Evidence-Based Practice Reports
Abstract: Breastfeeding mothers
are often are concerned about an
inadequate quantity of breast milk,
designated as insufficient milk supply.
Many breastfeeding mothers will attempt
to increase the quantity of breast milk
production by taking prescription
drugs and/or herbs and foods called
galactogogues. Galactogogues are defined
simply as substances that promote
lactation. The most common prescription
galactogogues are domperidone,
metoclopramide, metformin, and
oxytocin. Many common herbals and
foods have been traditionally used as
galactogogues. These galactogogues
will be reviewed; this information will
allow health care professionals in all
settings to provide consultative services
to breastfeeding mothers. Breastfeeding
mothers and supporters will find the
information useful to determine if
galactogogues are necessary, and if so,
which galactogogues are appropriate
for use. Treatment guidelines including
benefits, doses, actions, and cautions are
discussed.
Keywords: galactogogues;
domperidone; metoclopramide;
metformin; herbals; breastfeeding;
lactation
G
alactogogues may be considered
for insufficient milk supply when
nonpharmacologic interventions do
not aid in increasing milk supply.
Galactogogues typically increase prolactin
levels and thus initiate the breast milk
letdown reflex but also sometimes aid in
breast milk ejection. Multiple mechanisms
may come into play. Synthetic
galactogogues include dopamine
antagonists such as domperidone and
metoclopramide; antipsychotics such as
chlorpromazine, reserpine, sulpiride,
trifluoperazine, and thioridazine;
hormones such as oxytocin, growth
hormone, and recombinant human
prolactin; and miscellaneous agents such
as metformin.1-3 Domperidone,
metoclopramide, metformin, and oxytocin
are the most commonly used synthetic
galactogogues due to their relative efficacy
and safety in breastfeeding women. Many
herbals and foods are commonly used for
their galactogogue properties. The list is
quite extensive and includes alfalfa,
almonds, anise, asparagus, barley, basil,
beets, borage, caraway, carrots, chaste tree
fruit, cherries, chicken broth/soup/stock,
chickpeas (garbanzo beans), coconut,
coriander seeds, cumin, dandelion, dill,
fennel, fenugreek, flax seeds, garlic,
ginger, goat’s rue, green beans, hibiscus,
hops, lemon balm, lentils, lettuce,
malunggay (moringa), marshmallow root,
millet, molasses (black strap), mung,
mushrooms, nettle, oat straw (oats),
papaya, peas, pumpkin, quinoa seeds, red
clover, red raspberry, rice, sage, seaweed
soup, sesame seeds, spinach, sunflower
seeds, sweet potatoes, thistles, turmeric,
and vervain.4
Domperidone and metoclopramide are
unique antagonists of the dopamine D2
receptor site (dopamine causes a
decrease in prolactin levels), which are
used off-label to treat hypoprolactinemia
(insufficient milk supply), used to
increase prolactin levels. Of all the
prescription galactogogues, domperidone
seems to hold the most promise. Dr Tom
Hale recently obtained Orphan Drug
Status Designation from the Food and
Drug Administration (FDA) to study and
develop domperidone as a dedicated
prescription drug for the treatment of
hypoprolactinemia. Volume of milk
production per day has increased in
most, but not all, women, with increases
in milk volume occurring rapidly,
generally within 48 hours. Domperidone
rapidly facilitates prolactin release from
579718CANXXX10.1177/1941406415579718Infant, Child, & Adolescent NutritionInfant, Child, & Adolescent Nutrition
research-articleXXXX
Selection and Use of Galactogogues
Frank J. Nice, BS, MS, MPA, DPA
DOI: 10.1177/1941406415579718. Address correspondence to Frank J. Nice, Nice Breastfeeding, 7409 Algona Court, Derwood, MD 20855; e-mail: fjncat@hotmail.com.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2015 The Author(s)
“Many herbals and foods are commonly used for
their galactogogue properties.”
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no. 4 ICAN: Infant, Child, & Adolescent Nutrition
the pituitary within an hour and leads to
sustained, increased plasma levels soon
after; even in nonlactating women, levels
rise almost 10-fold. Doses are usually 10
to 20 mg 4 times a day or 30 mg 3 times
a day. Most breastfeeding mothers take
the drug for 3 to 8 weeks or as long as
needed to maintain supply.5,6 A 1-page
handout, including withdrawal
algorithms, is available at www.
nicebreastfeeding.com under “Counseling
Tips.”7 An issue that limits its use is that
domperidone currently does not have
prescription status in the United States.
In addition, despite having Orphan Drug
Status designated by the FDA for
treatment of insufficient milk supply, the
FDA has tried to limit its use as an
off-label drug to increase milk supply
due to apparently unrelated cardiac
issues in a different patient population.8
Unlike metoclopramide, domperidone
does not cross the blood–brain barrier
and does not tend to have adverse
effects such as drowsiness or depression
and, especially, tardive dyskinesia.
Metoclopramide is dosed at 10 mg 3 to 4
times a day for 1 week and then
gradually decreased over the next week.
Milk supply usually increases within
several days. Mothers must empty and/or
pump breasts 6 to 8 times a day and
make sure that the breasts are emptied
completely by nursing the baby or by
using a breast pump, even at night.9
Another drug used off-label as a
galactogogue is metformin. Its action is
not known but may be related to its
precursor, galegin, which is the active
ingredient of the herbal galactogogue,
Goat’s Rue. Its dose is 500 to 2500 mg
per day taken in 2 divided doses for 3 to
10 weeks.10 All 3 reviewed drugs result
in low concentrations in breast milk that
do not affect the infant.11
A lack of letdown is rarely a problem
for breastfeeding mothers, and when it is,
pharmacological solutions are often not
needed. Many times a good latch by the
baby will solve the problem, and if not,
breast compression may help. When these
methods fail, a nasal spray containing
oxytocin may stimulate the letdown reflex
in the mother. The dosage for use is one
spray in one or both nostrils 2 to 3
minutes before nursing or pumping of
breasts. There are compounding
pharmacists in the United States who can
and will compound an oxytocin nasal
spray when the patient has a doctor’s
prescription.12 Science is rapidly
expanding in researching biologics, and
recombinant human prolactin is no
exception. In a study to determine the
efficacy of recombinant human prolactin
to treat insufficient milk supply, this
biologic apparently was efficacious for
both mothers of preterm infants with
lactation insufficiency and mothers with
prolactin deficiency. The authors
recommended that long-term safety and
efficacy studies be conducted.3
Not all mothers have access to off-label
drugs nor desire to take prescription
drugs to increase milk supply.
Galactogogue herbals and foods are
regulated by the FDA as foods and not
medicines, as long as only “affects body
function” claims and not “medical” claims
are made. Because there is easier access
to these types of galactogogues, the
necessity exists for consumers to be well
informed and have a real need for
treatment before taking any herbal. Most
knowledge for herbal use comes from
the systematic collection of data in
Germany by the German Commission E
Monographs.13 Several published texts
provide useful herbal and food
galactogogue information, including the
following: The Nursing Mother’s Herbal,14
Medications and Mothers’ Milk,11
Nonprescription Drugs for the
Breastfeeding Mother,15 and The
Galactagogue Recipe Book.4
The following represents a list of some
of the more commonly used herbal and
food galactogogues, along with usual
galactogogue dosing (for more inclusive
information, see the articles, “Common
Herbs and Foods Used as
Galactogogues”16 and “Medications and
Breastfeeding: Current Concepts,”17
available at www.nicebreastfeeding.com
under “Counseling Tips”7):
Alfalfa (Medicago sativa): Up to 60 g
daily (1-2 capsules 4 times a day)
Anise (Anisi fructus): 3.5 to 7 g as
tincture or tea, 5 to 6 times a day
Barley (Hordeum vulgare): 15 g of
barley extract, 1 cup to 2 cups of
tea daily; 1 bottle of beer daily
Blessed Thistle (Cnici benedicti herba):
Up to 2 g, in capsule form, daily
Caraway (Carvi fructus): 1.5 to 6 g
daily as tincture, tea, or essential oil
Chaste Tree Fruit, Chasteberry, Vitex
(Agni casti fructus): 30 to 40 mg
daily as an alcoholic extract (50%
to 70% alcohol)
Coriander, Cilantro (Coriander
fructus): 3 g daily as tea
Dandelion (Taraxaci herba): 5 g, in
capsule form or as tincture or tea,
3 times a day
Dill (Anethi fructus): 3 g daily as
tincture or tea
Fennel (Foeniculi fructus): 0.1 to 0.6 mL
of oil (equal to 100-600 mg) daily
Fenugreek (Foenugraeci semen): 6 g,
in capsule form, daily
Garlic (Allii sativa bulbus): 4 to 9 g,
in capsule form, daily
Goat’s Rue (Galegae officinalis
herba): 1 to 2 mL of tincture, 2 to
3 times a day
Hops (Lupuli strobulus): 500 mg of dry
extract daily, 1 cup to 2 cups of tea
daily, 1 bottle of stout beer daily
Malunggay, Moringa (Moringa
oleifara): 250 mg, in capsule form
or as tea, 2 times a day
Marshmallow Root (Althaeae radix):
Two 500 mg capsules 3 times a
day or 60 g daily as tincture or tea
Milk Thistle (Cardui mariae herba):
12 to 15 g daily as infusion (equal
to 200-400 mg of silibinin
Oat Straw, Oats (Avenae
stramentum): 100 g daily
Quinoa (Chenopodium quinoa): 45 g
daily
Red Raspberry (Rubi idaei folium): 2.7
g as three 300 mg capsules 3 times
a day or daily as tincture or tea
Red Clover (Trifolium pretense): 40 to
80 mg daily as tincture or tea
Stinging Nettle (Urtica dioica and
Urtica urens): 1.8 g as one 600 mg
capsule 3 times a day, 1 cup of tea
2 to 3 times a day, 2.5 to 5 mL of
tincture 3 times a day
Vervain (Verbena officinalis): 30 to
50 g daily as tea
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ICAN: Infant, Child, & Adolescent Nutrition August 2015
The doses mentioned above represent
medicinal doses. Food equivalent
amounts of these herbals and many
others can be found in The Galactagogue
Recipe Book.4
As readers of this journal know,
breastfeeding has innumerable positive
health implications for breastfeeding
mothers and children. Therefore,
breastfeeding is recommended for all
willing and able mothers and infants.
Yet there are ever-present obstacles to
successful breastfeeding, even with the
most motivated mothers. One major
obstacle is the prevalence of
insufficient milk supply, which may be
as high as 15% in new mothers.3 The
causes are many, and all possible
causes should be investigated and
considered. As part of this consultative
evaluation, the selection and use of
galactogogues can be a viable and
reasonable choice. Information
presented in this article can be the
basis for making objective and
informative decisions.
Author Note
The author(s) declared no potential conflicts of
interest with respect to the research, authorship,
and/or publication of this article.
References
1. Forinash AB, Yancey AM, Barnes KN,
Myles TD. The use of galactogogues in the
breastfeeding mother. Ann Pharmacother.
2012;46:1392-1404.
2. Zuppa AA, Sindico P, Orchi C, Carducci
C, Cardiello V, Romagnoli C. Safety and
efficacy of galactogogues: substances
that induce, maintain and increase breast
milk production. J Pharm Pharm Sci.
2010;13:162-174.
3. Powe C, Allen M, Puopolo K. Recombinant
human prolactin for the treatment of
lactation insufficiency. Clin Endocrin (Oxf).
2010;73:645-653.
4. Nice FJ. The Galactagogue Recipe Book.
Plano, TX: Hale Publishing; 2014.
5. Campbell-Yeo MI, Allen AC, Joseph
KS, et al. Effect of domperidone on the
composition of preterm human milk.
Pediatrics. 2010;125:107-114.
6. Wan EW, Davey K, Page-Sharp M,
Hartmann PE, Simmer K, Ilett KF.
Dose-effect study of domperidone as
a galactogogue in preterm mothers
with insufficient milk supply, and its
transfer into milk. Br J Clin Pharmacol.
2008;66:283-289.
7. Nice Breastfeeding. Counseling tips. www.
nicebreastfeeding.com. Accessed January 6,
2015.
8. ILCA Consensus on Domperidone to
Support Lactation. http://rcp.nshealth.ca/
news/ilca-consensus-domperidone-support-
lactation. Accessed January 6, 2015.
9. Hansen WF, McAndrew S, Harris K,
Zimmermann MB. Metoclopramide effect
on breastfeeding the preterm infant:
a randomized trial. Obstet Gynecol.
2005;105:383-389.
10. Glueck CJ, Salehi M, Sieve I, Wang P.
Growth, motor, and social development
in breast- and formula-fed infants of
metformin-treated women with polycystic
ovary syndrome. J Pediatr. 2006;148:
628-632.
11. Hale TW, Rowe HE. Medications and
Mothers’ Milk. 16th ed. Plano, TX: Hale
Publishing; 2014.
12. University of Washington Medical Chapter.
Oxytocin nasal spray. https://healthonline.
washington.edu/document/health_online/
pdf/09-Oxytocin_Nasal_Spray_8_09.pdf.
Accessed January 6, 2015.
13. Blumenthal M, Busse WR, Goldberg A,
et al, eds. The Complete Commission E
Monographs: Therapeutic Guide to Herbal
Medicines. Austin, TX: American Botanical
Society; 1998.
14. Humphrey S. The Nursing Mother’s Herbal.
Minneapolis, MN: Fairview Press; 2003.
15. Nice FJ. Nonprescription Drugs for the
Breastfeeding Mother. 2nd ed. Amarillo, TX:
Hale Publishing; 2011.
16. Nice FJ. Common herbs and foods used as
galactogogues. Infant Child Adolesc Nutr.
2011;3:129-132.
17. Nice FJ, Luo AC. Medications and
breastfeeding: current concepts. J Am
Pharm Assoc (2003). 2012;52:86-94.
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