Published September 18, 2024 WOMEN'S HEALTH Practices and Products to Aid Lactation Amanda Rawa, PharmD Candidate 2025Nesbitt School of PharmacyWilkes UniversityWilkes-Barre, Pennsylvania Christina Bookwalter, PharmD, MS MEd, BCPS, BCACPClinical Pharmacist/Adjunct InstructorNesbitt School of PharmacyWilkes UniversityWilkes-Barre, Pennsylvania US Pharm. 2024;49(9):7-12.ABSTRACT: More women believe that they have an insufficient milk supply than those who actually do. This can cause anxiety over breast milk production, often leading to the introduction of formula or galactagogues. There are many reasons that lactation can decrease, including stress, alcohol use, maternal history, and medications. Pharmaceutical options including metoclopramide and domperidone can help, but they carry significant adverse effects. Herbal remedies such as fenugreek, milk thistle, and goat’s rue are used frequently. Nonpharmacologic practices to increase milk production include power pumping, adequate nutrition, and hydration. Women who are struggling with maintaining an adequate supply of breast milk should be referred to a lactation consultant.Galactagogues are medications or supplements that can help increase breast milk supply in women who are experiencing lactation insufficiency. Oxytocin and prolactin are the two main hormones involved in breast milk production. Oxytocin is released from the posterior pituitary gland during breastfeeding to widen the milk ducts and increase the flow and supply of milk to the infant. This hormone is related to the emotional state of the mother as well as physical interactions.1 For example, hearing her infant cry can induce oxytocin release, while experiencing high levels of stress can inhibit oxytocin release. Prolactin is secreted throughout the pregnancy to prepare the breast tissue for milk production, and it is released from the anterior pituitary during breastfeeding.1 An important factor in breast milk production is feedback inhibition. If milk is not removed from the breast, through either feeding or pumping, the inhibitor will pause production until the milk is cleared. Oxytocin and prolactin work in conjunction with the inhibitor to maintain regular lactation. Regular breastfeeding patterns preserve this balance and ensure proper emptying of milk.1 It is recommended to breastfeed for the first year of the infant’s life, but the overall recommendation states that there are benefits to breastfeeding for 6 months to 24 months, depending on environmental factors as well as the available milk supply. Breast milk provides the infant with a substantial nutrition source as well as immunologic factors that defend the infant from infectious diseases.2EpidemiologyMany mothers commonly discuss anxiety and stress in relation to their production of breast milk. Since breast milk provides nutrition and support for the growing infant, it is reasonable for these patients to have concerns over the amount of milk that they can consistently supply. This is a common reason for women to introduce formula feeding, seek the use of galactagogues, or discontinue breastfeeding altogether. An important distinction is that there is a difference between perceived breast milk supply and the actual breast milk supply of the patient. One study showed that up to 25% of lactating women believed that their supply of breast milk was less than expected, while only 5% of lactating women experienced actual breast milk insufficiency.3 Perceived insufficiency can cause unnecessary stress and lead to unneeded use of pharmaceutical products to bolster the production and supply of breast milk. Patients who believe that they are producing an insufficient amount of milk should consult their provider or a lactation consultant before attempting to use either pharmaceuticals or herbal galactagogues. Establishing Milk SupplyBreastfeeding is initiated by infant suckling, which causes oxytocin to allow the breast to release milk. The negative feedback cycle associated with oxytocin can contribute to breast milk insufficiency if the mother does not remove the milk through either breastfeeding or pumping.1 It is important for breastfeeding women to establish their breast milk supply early. Some best practices include breastfeeding within 1 hour of birth, giving newborns no food or drink other than breast milk, practicing rooming-in, breastfeeding on demand, and avoiding pacifiers or artificial nipples.4Factors That Raise Risk of Decreased LactationStress, including financial or emotional life events, can negatively affect breast milk supply. This can have a psychological effect on the mother, which can contribute to the patient discontinuing breastfeeding.1 Smoking tobacco products should be avoided during breastfeeding due to the risk of nicotine exposure, and smoking can also decrease breast milk supply by reducing prolactin levels.5Similarly, alcohol can decrease breast milk production if high amounts are consumed. Interestingly, beer has shown the opposite effect. Barley can increase prolactin levels, and some mothers use nonalcoholic beer to stimulate breast milk production. It should be recognized that alcohol can transfer to the feeding infant through breastfeeding, and it is recommended to avoid alcohol during breastfeeding.6 Alternatively, some women who choose to consume alcohol during this time will pump their breast milk and discard it shortly after drinking to prevent exposure to the infant. This practice is known as pump and dump. Per the CDC, women should wait 2 hours per drink before breastfeeding an infant.7Maternal medical history factors can contribute to decreased lactation, including difficulty breastfeeding or slow weight gain with previous children; endocrine disorders such as thyroid disease, diabetes, or polycystic ovary syndrome; autoimmune disease; or psychiatric issues.8Breast anatomy plays a role in lactation as well. Women do not have breasts that increase in size during pregnancy or have nipple variation such as inverted or very large nipples are at risk for low or inadequate milk supply. Primary mammary glandular insufficiency, defined as breasts that do not have enough milk-making tissue, often characterized as tubular breasts, also create an increased risk of low milk production. Women who have had breast surgery to include enlargement or reduction may also have difficulty with lactation.8Conditions that occur during the antepartum, intrapartum, or postpartum period can increase the risk of inadequate milk supply. These conditions include preeclampsia, gestational diabetes, prolonged labor, preterm delivery, postpartum hemorrhage, retained placenta, and medication administration during labor that can cause drowsiness in the newborn.8Drugs That Contribute to Decreased LactationSeveral medications can cause either the production or supply of breast milk to decrease through a variety of mechanisms. Notably, medications that have strong anticholinergic activity can decrease breast milk by inhibiting oxytocin and prolactin secretion.9 Diphenhydramine is an example of a common medication with anticholinergic side effects.10 Pseudoephedrine is a common OTC medication used to treat sinus congestion, and it is contraindicated in breastfeeding patients due to stimulating effects and irritation in the infant. It can also reduce breast milk production as a result of prolactin inhibition.11 Similarly, epinephrine at high doses has been shown to decrease milk supply by lowering serum prolactin levels.12Hormonal contraceptives that contain an estrogen component can lead to issues with lactation. Patients should avoid combined oral contraceptives during the first 3 weeks postpartum, but these products can be used during breastfeeding after this time. Of note, progestin-only contraceptives can be used postpartum and are not associated with decreased breast milk production.13Patients who take medications that could interfere with lactation should consult their provider to discuss the risks and benefits before discontinuing any of these drugs. In addition, the provider should assess if the medication is the probable cause of the patient’s decreased breast milk. Pharmaceutical Products to Increase Lactation Women who choose to use pharmaceutical products to stimulate breast milk production have limited options. Metoclopramide and domperidone are gastric motility stimulators that are also used off-label to help women who are struggling with maintaining an adequate breast milk supply. Domperidone has been available worldwide since 1978; however, in the United States it has never been approved for any indication.14 MetoclopramideMetoclopramide is a dopamine antagonist that increases prolactin levels. The increase in prolactin will initiate or augment milk production.15 Metoclopramide has a wide variety of other uses, including nausea and vomiting prophylaxis, gastroparesis, and refractory gastroesophageal reflux disorder.16 For increasing breast milk production, a common dosage is 10 mg by mouth three or four times daily.17 This dosage is similar to the other indications of metoclopramide.16 Patients who are taking this drug should be made aware of the black box warning associated with metoclopramide. Taking metoclopramide can lead to tardive dyskinesia, which is a movement disorder characterized by involuntary spastic motions primarily involving the face and mouth.16 There are limited treatments available for tardive dyskinesia other than discontinuing the causative agent, and the risk for this disorder is increased with high doses and longer durations of dopamine-blocking medications.18 For this reason, use of metoclopramide should be limited to less than 12 weeks of therapy. The current recommendation is to limit metoclopramide to 7 to 14 days when using it to aid lactation.19 Metoclopramide should be tapered when the patient is discontinuing therapy to avoid a sudden decrease in breast milk supply.17 Other side effects of this therapy include sedation, anxiety, restlessness, fatigue, drowsiness, and lassitude. Patients should be counseled on potential drug-drug interactions between metoclopramide and drugs such as monoamine oxidase inhibitors, tacrolimus, antihistamines, and antidepressants.16 The effects on the baby while a patient is taking metoclopramide and breastfeeding are minimal, including no adverse effects or increased intestinal gas.19 Overall, metoclopramide could be a reasonable option considering patient-specific factors and preferences. DomperidoneAnother option for patients who are struggling with breast milk sufficiency is domperidone. As mentioned previously, domperidone is not available commercially in the U.S., but it can be compounded by a compounding pharmacy or found via Internet pharmacies.20 Despite use in other countries, patients residing in the U.S. should be aware that this product is not regulated or approved by the FDA due to cardiac safety issues. Similar to metoclopramide, domperidone is a dopamine antagonist that is primarily used for gut motility. Domperidone is used off-label to increase prolactin and aid women experiencing breast milk–production issues.14 While it has a similar mechanism to metoclopramide, domperidone is associated with considerable safety risks. Domperidone could increase the risk of sudden cardiac death and is associated with increased risk of QT prolongation and arrhythmia.14 Patients should be instructed to report any symptoms of arrhythmia while taking domperidone since there is a proposed correlation with QT prolongation. When utilizing domperidone for breast milk production, most studies have done so at a dosage of 10 mg three times daily for 4 to 10 days.17 Domperidone can produce a wide range of side effects, including dry mouth, headache, dizziness, nervousness, agitation, drowsiness, diarrhea, and itchy skin. No adverse effects on the baby while a patient is taking domperidone were noted in small trials.20 Domperidone should not be abruptly discontinued due to a risk of psychiatric adverse events.20 Due to the cardiovascular safety risks associated with this medication, domperidone is not recommended for use. Specifically, mothers who have known cardiac arrhythmias or are taking medications that may cause cardiac arrythmias should avoid domperidone. Patients struggling with milk insufficiency should consider nonpharmacologic options or consult a lactation specialist.Herbal ProductsSeveral herbal products are commonly used for increasing the volume or production of breast milk in mothers who are struggling to produce a satisfactory amount. These products are generally well tolerated, although evidence is limited. Fenugreek is an herb from the pea family. It is the most commonly utilized herbal galactagogue in the world. The mechanism of action is unknown; however, it is thought to increase milk flow and milk production.21 Dosing of fenugreek varies. It is available in multiple different products, including traditional capsules and teas but also edible products such as cookies. Overall, fenugreek is generally well tolerated, with the most common side effects being abdominal pain, bloating, and diarrhea. Another side effect that has been reported is maple syrup–like body odor. There are also certain cross-reactivity issues with fenugreek. Patients with allergies or sensitivities to plants such as ragweed, peanuts, chickpeas, soybeans, and green beans should employ caution when considering the use of fenugreek, as this cross-reactivity may lead to anaphylaxis.22 Milk thistle, or Silybum marianum, is another herbal product used for increasing lactation, though little evidence supports the use of this product.23 Milk thistle is generally well tolerated. There is a possible risk for allergic cross-reaction in patients who are sensitive to ragweed and related plants. The most common adverse effects include mild gastrointestinal side effects such as abdominal bloating, diarrhea, dyspepsia, and nausea.23 Very few studies have been published examining the use of milk thistle for increasing lactation, and the few that have been published do not demonstrate substantial efficacy. Goat’s rue has also been associated with lactation. The proposed mechanism is production of breast milk though stimulation of prolactin. In terms of safety, there is insufficient evidence to support the safe use of goat’s rue, but overall, it is well tolerated.24There are various herbal products that are available for improving lactation, though evidence is lacking and there is a risk for side effects. Pharmacists should be aware that these natural products are available in multiple traditional and nontraditional dosage forms. They should also be aware that many products marketed to assist lactation could be combination products. It is important to counsel patients to first focus on nonpharmacologic ways to aid breast milk production. Nonpharmacologic Practices to Increase Lactation Women are often told to increase their water or caloric intake to increase their milk production. There is little evidence to support the idea that increasing fluid intake will increase breast milk production. A 2014 Cochrane review was performed on the topic, but only one trial met the inclusion criteria. Therefore, the overall Cochrane conclusions note that advantages of additional fluids for breastfeeding mothers remain unknown due to a lack of well-conducted trials. The recommendation is that breastfeeding mothers should consume a fluid intake to meet their physiologic needs.25Breastfeeding mothers also need to be aware of their diet for milk production. The body requires energy to produce breast milk; therefore, adequate nutrition is imperative. Per the U.S. Department of Agriculture and the U.S. Department of Health and Human Services Dietary Guidelines for Americans, lactating women require an additional 330 calories during the first 6 months of lactation, then an additional 400 calories during the second 6 months of lactation. These estimates apply only to women with a healthy prepregnancy weight.26 Women should consider the nutritional value of their food and focus on consuming a well-balanced diet. There is not strong evidence to support the concept of certain foods increasing milk production. Patients should be cautious of marketing for food products that make lactation claims. Moreover, women need to ensure adequate nutritional intake, but excess intake has not been shown to increase milk production.Power pumping is commonly discussed in the breastfeeding community as a way to increase milk supply. Power pumping includes intervals of using a breast pump to remove milk and pauses. The pauses are brief and induce an increase in prolactin, thereby having a positive effect on milk production. One method of power pumping is to alternate 15 minutes of pumping time with a 10-minute pause time for a total of three cycles once a day. Women should know that power pumping may not cause an immediate increase in milk output; rather, the point is to stimulate the breasts for future milk production. For many women, a noticeable increase in the amount of milk can be seen within 3 days; however, others might not see changes until after 14 days of power pumping.27 Overall, if a lactating woman is faced with low milk production, power pumping can be considered to increase milk supply.Lactation Consultant Women who are concerned with their milk production should seek out a lactation consultant or expert. These professionals are trained to aid their patients with breastfeeding by looking primarily at nonpharmacologic measures to increase breast milk production and ensure that the infant is receiving adequate nutrition.28 A lactation expert will review the latch of the child to the breast. Signs of a good latch include the infant’s chest resting against the mother’s body, the infant’s chin on the breast, the tongue down, the lips flanged outward, little or no visible areola, rhythmic sucking, audible swallowing, and the latch not being uncomfortable or painful to the mother. Lactation experts will also assess the child for signs of tongue-tie or lip-tie, which may affect the amount of milk the baby is able to transfer from the mother.8 Lactation experts can impart support and education to the mother, assess safety and nutritional status of the infant, and provide encouragement for the continuation of effective breastfeeding. These consultants are credentialed through the International Board of Lactation Consultant Examiners, and they can be found within hospital systems or at related practice sites.28 Women struggling with breastfeeding should consult a lactation expert and receive individualized care to optimize their breast milk production and ensure proper nutritional support for the infant.The Pharmacist’s role Pharmacists can play a vital role in aiding women who face challenges with lactation. Pharmacists should be familiar with common nonpharmacologic techniques to improve breast milk production and be prepared to counsel on any prescription or herbal galactogogues. The support of a lactation consultant is invaluable for women facing breastfeeding challenges. These professionals can provide tailored advice, support, and interventions to help mothers maintain an adequate milk supply and ensure that their infants receive sufficient nutrition. Pharmacists should be aware of the services available in their community to refer women to these critical healthcare providers when there are lactation concerns.REFERENCES1. Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals. Geneva, Switzerland: World Health Organization; 2009. SESSION 2, The physiological basis of breastfeeding. www.ncbi.nlm.nih.gov/books/NBK148970/.2. Scott J, Ahwong E, Devenish G, et al. Determinants of continued breastfeeding at 12 and 24 months: results of an Australian cohort study. Int J Environ Res Res Public Health. 2019;16(20):3980.3. Huang Y, Liu Y, Yu XY, Zeng TY. The rates and factors of perceived insufficient milk supply: a systematic review. Matern Child Nutr. 2022;18(1):e13255.4. ACOG Committee Opinion No. 756: Optimizing support for breastfeeding as part of obstetric practice. Obstet Gynecol. 2018;132(4):e187-e196.5. Primo CC, Ruela PBF, Brotto LDA, et al. Effects of maternal nicotine on breastfeeding infants. Rev Paul Pediatr. 2013;31(3):392-397.6. Drugs and Lactation Database (LactMed) [Internet]. Bethesda, MD: National Institute of Child Health and Human Development; 2006-. Alcohol. Updated April 15, 2024. www.ncbi.nlm.nih.gov/books/NBK501469/.7. CDC. Breastfeeding special circumstances. February 26, 2024. www.cdc.gov/breastfeeding-special-circumstances/hcp/vaccine-medication-drugs/alcohol.html. Accessed June 25, 2024.8. Breastfeeding challenges: ACOG Committee Opinion, Number 820. Obstet Gynecol. 2021;137(2):e42-e53.9. Drugs and Lactation Database (LactMed) [Internet]. Bethesda, MD: National Institute of Child Health and Human Development; 2006-. Atropine. Updated February 15, 2021. www.ncbi.nlm.nih.gov/books/NBK501471/.10. Drugs and Lactation Database (LactMed) [Internet]. Bethesda, MD: National Institute of Child Health and Human Development; 2006-. Diphenhydramine. 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Metoclopramide product information. Jacksonville, FL: Ranbaxy; 2012.17. Brodribb W. ABM Clinical Protocol #9: Use of Galactagogues in Initiating or Augmenting Maternal Milk Production, Second Revision 2018. Breastfeed Med. 2018;13(5):307-314.18. Al-Saffar A, Lennernäs H, Hellström PM. Gastroparesis, metoclopramide, and tardive dyskinesia: risk revisited. Neurogastroenterol Motil. 2019;31(11):e13617.19. Drugs and Lactation Database (LactMed) [Internet]. Bethesda, MD: National Institute of Child Health and Human Development; 2006-. Metoclopramide. Updated May 15, 2024. www.ncbi.nlm.nih.gov/books/NBK501352/.20. Drugs and Lactation Database (LactMed) [Internet]. Bethesda, MD: National Institute of Child Health and Human Development; 2006-. Domperidone. Updated May 15, 2024. www.ncbi.nlm.nih.gov/books/NBK501371/.21. Turkyılmaz C, Onal E, Hirfanoglu IM, et al. The effect of galactagogue herbal tea on breast milk production and short-term catch-up of birth weight in the first week of life. J Altern Complement Med. 2011;17(2):139-142.22. Fenugreek. In: NATMED Pro. Trc healthcare. Updated May 2024. https://naturalmedicines.therapeuticresearch.com/databases/food,-herbs-supplements/professional.aspx?productid=733. Accessed June 25, 2024.23. Milk thistle. In: NATMED Pro. Trc healthcare. Updated February 2024. https://naturalmedicines.therapeuticresearch.com/databases/ food,-herbs-supplements/professional.aspx?productid=138. Accessed June 25, 2024.24. Goat’s rue. In: NATMED Pro. Trc healthcare. Updated July 2023. https://naturalmedicines.therapeuticresearch.com/databases/food,-herbs-supplements/professional.aspx?productid=160. Accessed June 25, 2024.25. Ndikom CM, Fawole B, Ilesanmi RE. Extra fluids for breastfeeding mothers for increasing milk production. Cochrane Database Syst Rev. 2014;2014(6):CD008758.26. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020−2025. 9th ed. December 2020. www.DietaryGuidelines.gov. Accessed June 25, 2024.27. European Lactation Consultants Alliance. “Power-pumping”–super stimulation for milk production. 2016. www.elacta.eu/wp-content/uploads/2017/04/Handout-2016-4-EN-Power-Pumping-1.pdf. Accessed August 12, 2024.28. International Board of Lactation Consultant Examiners. About IBLCE. May 8, 2017. https://iblce.org/about-iblce/. Accessed August 12, 2024. The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.To comment on this article, contact rdavidson@uspharmacist.com.