Related Terms

• Alveoli, ankyloglossia, arachidonic acid, areola, breast, breast feeding, breast milk stimulant, breast pump, candida, candidiasis, cortisol, DHA, docosahexaenoic acid, ejection reflex, estrogen, galactagogue, HPL, human placental lactogen, hypercalcemia, hypoplastic, hypotonia, IgA, immunoglobulin A, insulin, lactation, lactation stimulation, lactogenesis I, lactogenesis II, lactogenesis III, mammary glands, mastitis, milk ejection reflex, nursing, oxytocin, passive immunity, progesterone, prolactin, thrush, thyroxin, tracheo-oesophageal fistula.

Background

• Lactation describes the secretion of milk from the mammary glands, and nursing describes the process of providing breast milk to the young. This process occurs in all female mammals, and in humans it is commonly referred to as breastfeeding. In humans and most species, milk comes out of the mother's nipples.

• Babies have a sucking reflex that enables them to suck and swallow milk. Both babies and mothers gain many benefits from breastfeeding. Breast milk is easy to digest and contains antibodies that can protect infants from bacterial and viral infections. Some of the nutrients in breast milk, such as protein and vitamins, help protect an infant against some common childhood illnesses and infections, such as diarrhea, middle ear infections, and certain lung infections. Research indicates that women who breastfeed may have lower rates of certain breast and ovarian cancers.

• Colostrum is the first milk produced by the mother during the initial days after giving birth. Colostrum is low in fat and high in carbohydrates, protein, and antibodies to help develop and support the baby's immune system.

• Breastfed infants and infants who are fed breast milk have fewer deaths during the first year and experience fewer illnesses than babies fed formulas.

• Research also suggests that breast milk contains important fatty acids (building blocks of cells) that help an infant's brain develop. Two specific fatty acids, docosahexaenoic acid (DHA) and arachidonic acid (AA), are components of the brain and are important for developing cognitive skills. Many types of infant formulas available in the United States are fortified with DHA and AA.

• While there are conflicting studies about the relative value of artificial feeding, including infant formula, it is acknowledged to be inferior to breastfeeding for both full-term and premature infants. In many countries, artificial feeding is commonly associated with illness and death in infants.

• National governments and international organizations, including the World Health Organization (WHO) and the American Academy of Pediatrics (AAP), promote breastfeeding as the best method of feeding infants in their first years of life and beyond. Although breastfeeding is widely regarded as superior to artificial feeding, authorities also encourage the development of safe and improved artificial feeding methods.

• Not all the properties of breast milk are understood, but its nutrient content has been well studied. The nutrients in breast milk come from the mother's blood and body. Some studies estimate that in women who exclusively breastfeed, 400-600 extra calories a day are used to produce milk. The water, fat, and nutrient content in breast milk may vary depending on several factors, including the manner in which the baby nurses, the mother's food consumption, and the environment.

• Certain medications may pass through the breast milk to the infant when women who are breastfeeding are taking the drugs. Because of the infant's small size and the difference in metabolism between infants and adults, occasionally this transfer of medication can be harmful to the infant. The majority of drugs that are given to breastfeeding women do not cause problems in infants. Questions regarding which drugs are safe to take when breastfeeding should be directed toward a healthcare provider.

Causes of Lactation

• General: Starting in the fourth month of pregnancy, the system in a woman's breast begins to develop. Milk production is affected by several hormones, namely prolactin and oxytocin.

• Progesterone: Progesterone levels are increased during pregnancy and drop after birth. This triggers copious milk production by the glands (called alveoli) in the breast lobe (lactating gland) that produces milk.

• Estrogen: Estrogen stimulates the milk duct system to mature. Estrogen levels also drop at delivery and remain low for the first several months of breastfeeding. Healthcare professionals recommend that breastfeeding mothers avoid estrogen-based birth control methods, as a spike in exogenous (from outside the body) estrogen levels may reduce a mother's milk supply.

• Prolactin: Prolactin contributes to the increased growth of the alveoli during pregnancy.

• Oxytocin: Oxytocin causes smooth muscle contraction and causes the uterus to contract around the time of birth. Oxytocin causes the smooth muscle layer of band-like cells surrounding the alveoli to squeeze the newly-produced milk into the duct system. Oxytocin is necessary for the milk ejection reflex and for milk expression to occur.

• Human placental lactogen: Human placental lactogen (HPL) is released by the placenta during the second month of pregnancy. HPL appears to aid in breast, nipple, and areola growth before birth.

• By the fifth or sixth month of pregnancy, the breasts are ready to produce milk. It is also possible to induce lactation without pregnancy through chemical methods using certain drugs.

• Lactogenesis: The process of milk production is called lactogenesis, which is divided into three stages.

• Lactogenesis I: During the latter part of pregnancy, the woman's breasts enter into the lactogenesis I stage. This is when the breasts make colostrum (the first milk produced by the mother after birth). At this stage, high levels of progesterone inhibit most milk production. It is not a medical concern if a pregnant woman leaks colostrum before her baby's birth, nor is it an indication of future milk production.

• Lactogenesis II: At birth, prolactin levels remain high, while the delivery of the placenta results in a sudden drop in progesterone, estrogen, and HPL levels. This abrupt withdrawal of progesterone in the presence of high prolactin levels stimulates the copious milk production of lactogenesis II.

• When the breasts are stimulated, prolactin levels in the blood rise, peak after about 45 minutes, and return to the pre-breastfeeding state about three hours later. The release of prolactin triggers the cells in the alveoli to make milk. Some research indicates that prolactin in milk is higher at times during the milk production process, and that the highest levels tend to occur between 2 a.m. and 6 a.m.

• Other hormones, notably insulin, thyroxine (thyroid hormone), and cortisol (the stress hormone), are also produced during lac II, but their roles are not yet well understood. Although biochemical markers indicate that lactogenesis II begins within 30-40 hours of birth, mothers do not typically begin feeling increased breast fullness until two to three days after birth.

• Colostrum is the first milk secreted or produced by the breast. It contains higher amounts of white blood cells and antibodies than mature milk. Antibodies are proteins made by the immune system to fight foreign substances, such as bacteria or viruses, in the body. Colostrum is especially high in immunoglobulin A (IgA) class of antibodies. These antibodies coat the lining of the baby's immature intestines and help prevent germs from invading the baby's system. Secretory IgA also helps prevent food allergies. During the first two weeks after the birth, colostrum production slowly gives way to mature breast milk.

• Lactogenesis III: The hormonal endocrine control system aids in milk production during pregnancy and the first few days after the birth. When the milk supply is more firmly established, the autocrine (or local) control system begins. This stage is called lactogenesis III. During this stage, the more that milk is removed from the breasts, the more the breast will produce milk. Draining the breasts more fully also increases the rate of milk production, thus the milk supply is strongly influenced by how often the baby feeds and how well the mother is able to transfer milk from the breast. Low milk supply can often be traced to: not feeding or pumping often enough; inability of the infant to transfer milk effectively caused by jaw or mouth structure deficits or poor latching technique; rare maternal endocrine disorders; hypoplastic breast tissue; a metabolic or digestive inability in the infant, making the baby unable to digest the milk he/she receives; and inadequate calorie intake or malnutrition of the mother.

• Milk ejection reflex: The release of the hormone oxytocin leads to the milk ejection or let-down reflex. Oxytocin stimulates the muscles surrounding the breast to squeeze out the milk. Breastfeeding mothers describe the sensation differently. Some feel a slight tingling, others feel immense amounts of pressure or slight pain/discomfort, and still others do not feel any difference.

• The milk ejection reflex is not always consistent. Stress or anxiety can cause difficulties with breastfeeding. The thought of breastfeeding or the sound of any baby can stimulate this reflex, causing unwanted leakage Also, both breasts may give out milk when an infant is feeding from one breast. However, these problems often subside after two weeks of feeding.

• A poor milk ejection reflex can be due to sore or cracked nipples, separation from the infant, a history of breast surgery, or tissue damage from prior breast trauma. If a mother has trouble breastfeeding, different methods of assisting the milk ejection reflex may help. These include feeding in a familiar and comfortable location, massage of the breast or back, or warming the breast with a cloth or shower.

• Afterpains: Afterpains occur with increased levels of the hormone oxytocin. Oxytocin triggers the milk ejection reflex and also causes the uterus to contract. These pains may range from period-like cramps to strong labor-like contractions. The afterpains can be more severe with second and subsequent babies.

• Lactation without pregnancy: It is also possible to induce lactation without pregnancy. Women who have never been pregnant are sometimes able to induce enough lactation to breastfeed. This is called "induced lactation." A woman who has breastfed before and re-starts is said to "relactate." If the nipples of a non-pregnant woman are consistently stimulated by a breast pump or actual suckling, the breasts will eventually begin to produce enough milk to begin feeding a baby. Once established, lactation adjusts according to demand. This is how some adoptive mothers, usually beginning with a supplemental nursing system or some other form of supplementation, are able to breastfeed. There is thought to be little or no difference in milk composition whether lactation is induced or a result of pregnancy.

• Also, rare accounts of male lactation may occur. Some drugs, primarily atypical antipsychotics such as risperidone (Risperdal®), may cause lactation in both women and men.

Breastfeeding

• Healthcare professionals recommend the following techniques for breastfeeding:

• With a free hand, place the thumb on top of the breast and the other fingers below the breast. Do not touch the areola (the dark skin around the nipple). The areola is where the baby's lips will be.

• Touch the baby's lips with the nipple until the baby opens his or her mouth very wide. Put the nipple all the way in the baby's mouth and pull the baby's body close. This lets the baby's jaw squeeze the milk ducts under the areola.

• When the baby is "latched on" the right way, both lips should pout out (not be pulled in over his or her gums) and cover nearly all of the areola. Instead of smacking noises, the baby will make low-pitched swallowing noises. The baby's jaw may move back and forth. If pain is felt while the baby is nursing, he or she is probably not latched on correctly.

• The baby's nose may be touching the breast during nursing. Babies' noses are designed to allow air to get in and out in just such a case. But if the individual is concerned that the baby cannot breathe easily, they can gently press down on the breast near the baby's nose to give him or her more room to breathe.

• Holding the baby: A baby can be held in a number of ways during breastfeeding. The baby should not have to turn his or her head or strain his or her neck to nurse. In the cradle position, put the baby's head in the crook of the arm. Support the baby's back and bottom with the arm and hand. The baby will be lying sideways facing the individual. The mother's breast should be right in front of the baby's face.

• The football position consists of tucking the baby under the arm like a football with his or her head resting on the hand. Support the baby's body with the forearm. This may be a good position if the mother is recovering from a cesarean section or if the baby is very small.

• Mothers can also lie on their side with the baby facing the breast. Pillows can be used to prop up the mother's head and shoulders. This is also a good position if the mother is recovering from a cesarean section or an episiotomy.

• Milk ejection reflex: A few seconds to several minutes after the breastfeeding is started, the mother may feel a tingle in her breast, and milk may start to drip from the breast not being used. These are signs that the milk is ready to flow.

• This milk ejection reflex makes breastfeeding easier for the baby. Let-down may also occur if a feeding is overdue, if the mother hears the baby cry, or even while the mother is thinking about the baby.

• Milk ejection can be forceful enough to cause the baby to cough. If this is a problem, the mother can express some of her milk by hand before a feeding to bring on the ejection reflex before starting breastfeeding.

• Feeding frequency: Feed the baby as often as he or she wants to be fed. This may be eight to 12 times a day or more. How often a baby wants to feed may change over time as he or she goes through growth spurts. Growth spurts occur at about two and six weeks of age and again at about three and six months of age.

• Let the baby nurse until he or she is satisfied. This may be for about 15-20 minutes at each breast. Try to have the baby nurse from both breasts at each feeding. Signs that the baby is getting enough milk include: acts satisfied after each feeding and gains weight constantly after the first three to seven days after birth (the baby may lose a little weight during the first week after being born); have about six to eight wet diapers a day; and have about two to five or more stools a day at first. After the first week, the infant may then have two or less stools a day. Stools will be runny at first. If the mother is nursing fewer than eight times a day, it is especially important to be aware of these signs.

• Increasing milk supply: If the baby needs more milk, increase the number of feedings a day. It is also important for the mother to get plenty of rest, eat a healthy, well-balanced diet, and drink plenty of fluids. Giving the body time to catch up to the baby's demands is important to producing enough milk.

• Before breastfeeding, mothers can put a warm compress over the breasts for about 15 minutes to increase milk flow. Alternatively, patients can take warm showers and/or gently massage the breasts to increase milk flow. Do not start giving the baby formula or cereal. If formula or cereal is given to the baby, he or she may not want as much breast milk. This will decrease the mother's milk supply. Also, the baby does not need any solid foods until he or she is four to six months old.

• Diet: The best diet for a breastfeeding woman is well-balanced and has plenty of calcium. Eating fresh fruits and vegetables, whole-grain cereals and breads, meats or beans, and milk and dairy foods like cheese is recommended by healthcare professionals. The mother will need to get enough calories - about 500 more per day than usual. The mother will also need to drink plenty of fluids.

• A balanced diet that includes five servings of milk or dairy products each day will give the mother enough calcium. If the mother does not eat meat or dairy products, the calcium needed can be obtained from broccoli, sesame seeds, tofu (soy), and kale. Also, calcium supplementation is available. A doctor or healthcare provider can help the mother with dietary issues.

• If foods bother the baby, it is recommended by healthcare professionals to stop eating the food causing a problem. Caffeine and alcohol can get into the mother's milk, so mothers should limit these substances. Drugs, including non-prescription and prescription items, can also get into the mother's milk. It is best not to take anything without talking to a doctor first. Also, if the mother smokes, nursing is another good reason to try to quit. Smoking can cause the mother to make less milk and the chemicals in cigarettes and smoke can get into the milk.

Complications

• While breastfeeding difficulties are not uncommon, putting the baby to the breast as soon as possible after birth helps to avoid many problems. Many breastfeeding difficulties can be resolved with proper hospital procedures, properly trained nurses and hospital staff, and lactation consultants. Some factors that may interfere with successful breastfeeding include: formula feeding; artificial nipples or dummies (pacifiers); thrush (yeast infection in the baby's mouth); distractions or interruptions during feeds; long separations from the mother; rapid breathing (tachypnea) such as transient tachypnea of the newborn, surfactant deficiency, respiratory distress syndrome, or other infant medical conditions; swallowing difficulties such as with prematurity and coordination of sucking, swallowing and breathing, or gastro-intestinal tract abnormalities like tracheo-oesophageal fistula; pain resulting from surgical procedures like circumcision, blood tests, or vaccinations; difficulties latching onto the breast; poor sucking reflex; poor stamina; hypoplastic breasts/insufficient glandular tissue; cleft palate; ankyloglossia (tongue tie); hypoglycemia or hyperglycemia; hypotonia or "low-tone" infant disorder; hyperlactation syndrome (too much breast milk production); and overactive let-down.

• Premature babies can have difficulties coordinating their sucking reflex with breathing. They may also tire during feeding. Premature infants unable to take enough calories by mouth may need enteral or g-tube feeding (inserting a feeding tube into the stomach to provide enough breast milk or a substitute). This is often done together with prolonged skin-to-skin contact with the mother (called Kangaroo care), which makes later breastfeeding easier.

• Breast pain: Pain often interferes with successful breastfeeding. Breast pain is the second most common cause for the abandonment of exclusive breastfeeding after perceived low milk supply.

• Engorgement: Engorgement is the sense of breast fullness experienced by most women within 36 hours of delivery. Normally, this is a painless sensation of "heaviness." Breastfeeding on demand is the primary way of preventing painful engorgement.

• When the breast overfills with milk, it becomes painful. Engorgement comes from not getting enough milk from the breast. It happens about three to seven days after delivery and occurs more often in first-time mothers. The increased blood supply, the accumulated milk, and the swelling all contribute to the painful engorgement. Engorgement may affect the areola, the periphery of the breast, or the entire breast and may interfere with breastfeeding both from the pain and also from the distortion of the normal shape of the areola/nipple. This makes it harder for the baby to latch on properly for feeding. Latching may occur over only part of the areola. This can irritate the nipple more and may lead to ineffective drainage of breast milk and more pain. Engorgement may begin as a result of several factors such as nipple pain, improper feeding technique, infrequent feeding, or infant-mother separation.

• To prevent or treat engorgement, remove the milk from the breast by breastfeeding, expressing, or pumping. Gentle massage can help start the milk flow and reduce the pressure. The reduced pressure softens the areola, perhaps even allowing the infant to feed. Warm water or warm compresses and expressing some milk before feeding can also help make breastfeeding more effective. After breastfeeding, mothers can apply cold compresses to further reduce swelling and pain. One published study suggested the use of "chilled cabbage leaves" applied to the breasts. Attempts to reproduce this technique met with mixed results.Non-steroidal anti-inflammatory drugs, such as ibuprofen (Motrin®, Advil®) or acetaminophen (Tylenol®), may help relieve the pain. Check with a healthcare professional before using any non-prescription medication or dietary supplement while breastfeeding.

• Nipple pain: Sore nipples are probably the most common complaint after the birth. They are generally reported by the second day after delivery but improve within five days. Pain beyond the first week, severe pain, cracking, fissures, or localized swelling is not normal. The mother should see a doctor for further evaluation. Sore nipples, a common cause of pain, often come from the baby not latching on properly. Factors include too much pressure on the nipple when not enough of the areola is latched onto and an improper release of suction at the end of the feeding. Improper use of breast pumps or topical remedies can also contribute. Nipple pain can also be a sign of infection.

• Candidiasis: Symptoms of candidiasis, or yeast infection, of the breast include pain, itching, burning and redness, or a shiny or white patchy appearance. The baby could have a white tongue that does not wipe clean. Candidiasis is common and may be associated with infant thrush. Both mother and baby must be treated to get rid of this infection; first-line therapies include nystatin, ketaconacole, or miconazole applied to the nipple and given by mouth to the baby. Strict cleaning of clothing and breast pumps is also required to eradicate the infection.

• Milk stasis: Milk stasis is when a milk duct is blocked and cannot drain properly. This may affect only a part of the breast and is not associated with any infection. It can be treated by varying the baby's feeding position and applying heat before feeding. If it happens more than once, further evaluation is needed. Mothers are also encouraged to let their babies completely empty one breast before switching to the other. This helps prevent milk stasis.

• Mastitis: Mastitis is inflammation of the breast. It causes local pain, redness, swelling, and fever. Later stages of mastitis cause symptoms of systemic infection such as fever and nausea. Mastitis generally occurs two to three weeks after delivery but can happen at any time. It typically results from milk stasis with primary or secondary local, later systemic infection. Infectious organisms include Staphylococcus sp., Streptococcus sp., and E. coli. Prompt treatment can prevent complications, such as abscess formation. Mastitis that is caused by an infection is treated with antibiotics and self-care techniques, such as warm compresses and gentle massaging, to increase milk flow and reduce pain. Mothers with mastitis can safely continue breastfeeding because the infection cannot be passed through the breast milk. In fact, keeping the milk flowing in the infected breast helps get rid of the infection. If the nipples are too painful to continue breastfeeding, a breast pump may be used to empty the breast. However, some antibiotics may be harmful for nursing infants. Severe cases may require intravenous antibiotics. Patients should ask their doctors if they can continue breastfeeding while taking medications.

Integrative Therapies

• Unclear or conflicting scientific evidence:

• Asparagus: Asparagus (Asparagus officinalis) may help promote the secretion of milk in women. There is currently not enough scientific evidence to recommend asparagus during pregnancy and breastfeeding. Additional study is needed to better understand the potential galactagogue (breast milk stimulant) properties of asparagus.

• Avoid if allergic or hypersensitive to asparagus or other members of the Liliaceae family. Use cautiously with edema (accumulation of fluid) caused by impaired kidney or heart function. Studies testing the safety of asparagus for pregnant or breastfeeding mothers are currently lacking in the available literature.

• Coleus: Coleus has been used as a breast milk stimulant for hundreds of years, however, this traditional use has not been well documented and scientific evidence is limited. Additional study is needed to make a conclusion.

• Avoid if allergic to Coleus forskohlii and related species. Use cautiously with diabetes, thyroid disorders, heart disease, asthma, low blood pressure, or if at risk of developing low blood pressure. Use cautiously with a history of bleeding, homeostatic disorders, or drug-related homeostatic problems. Use cautiously if taking asthma medications (e.g. bronchodilators), anticoagulants, anti-thrombotic agents, or anti-platelet medications. Do not use two weeks before and immediately after surgical or dental procedures that have bleeding risks. Avoid if pregnant or breastfeeding.

• Fenugreek: Fenugreek has been used in Indian and Chinese medicine to help with labor and digestion. Traditionally in India, fenugreek has been used to increase milk flow. Additional study is needed to better understand the use of fenugreek as a galactagogue (breast milk stimulant).

• Avoid if allergic to fenugreek or chickpeas. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risks. Use cautiously with asthma, diabetes, or with a history of ulcers or stroke. Avoid if pregnant. Children should not take doses larger than those commonly found in foods.

• Jasmine: In the Ayurvedic tradition, jasmine has been used for lactation suppression. Preliminary clinical study found that application of jasmine flowers to the breast significantly decreased prolactin levels, breast engorgement, and milk production. More higher-quality studies are needed in this area.

• Use cautiously during pregnancy. Use cautiously in patients allergic to jasmine, jasmine oil, or other fragrances. Use cautiously during lactation. Avoid oral consumption of essential oils, including jasmine essential oil, as they are extremely potent and can be poisonous.

• Vitamin B6: The body needs vitamin B6, or pyridoxine, to make the neurotransmitters serotonin and norepinephrine, as well as myelin. Studies evaluating pyridoxine for lactation suppression have yielded mixed results. Well-designed clinical trials are needed before a firm conclusion can be drawn.

• Some individuals seem to be particularly sensitive to vitamin B6 and may have problems at lower doses. Avoid excessive dosing. Vitamin B6 is likely safe when used orally in doses not exceeding the recommended dietary allowance (RDA).

• Traditional or theoretical uses lacking sufficient evidence:

• Acupuncture: The practice of acupuncture originated in China 5,000 years ago. Today, it is widely used throughout the world and is one of the main pillars of Chinese medicine. Although not studied clinically, acupuncture has been traditionally used for increasing breast milk production.

• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, or neurological disorders. Avoid if taking drugs that increase the risk of bleeding (e.g. anticoagulants). Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (e.g. asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers because therapy may interfere with the device.

• Alfalfa: Although not studied clinically, alfalfa (Medicago sativa) has been traditionally used for increasing breast milk production. Alfalfa appears to be well tolerated by most individuals, although rare serious adverse effects have been reported.

• Blood sugar levels may be reduced. Caution is advised in those with diabetes or hypoglycemia, and in those taking drugs, herbs, or supplements that affect blood sugar. Serum glucose levels may need to be monitored by a healthcare provider, and medication adjustments may be necessary. Avoid if allergic to alfalfa, clover, or grass. Avoid with a history of lupus, thyroid disease, gout, blood clots, seizures, liver disease, or kidney disease. Use cautiously with stroke, hormonal conditions (e.g. breast tenderness, breast cancer, ovarian cancer, or menstrual problems. Avoid if taking drugs that increase the risk of bleeding (e.g. aspirin, aspirin products, or warfarin) or ibuprofen. Do not use two weeks before and immediately after any surgery/dental/diagnostic procedures that may have bleeding risks. Alfalfa may be contaminated with dangerous bacteria (e.g. E. coli, salmonella, or listeria).

• Bilberry: Bilberry (Vacinnium myrtillus), a close relative of blueberry, has a long history of medicinal use. Although not studied clinically, bilberry has traditionally been used for lactation suppression.

• There is currently not enough scientific evidence to recommend the safe use of bilberry during pregnancy or breastfeeding, although eating bilberry fruit is believed to be safe based on its history of use as a food. Limited available study used bilberry extract to treat pregnancy-induced leg swelling (edema) and no adverse effects were reported. Avoid if allergic to plants in the Ericaceae family or to anthocyanosides (a component of bilberry). Avoid with a history of low blood pressure, heart disease, bleeding, diabetes, blood clots, or stroke. Stop use two weeks before and immediately after surgeries/dental or diagnostic procedures with bleeding risks.

• Chasteberry: Chaste tree (Vitex agnus-castus) is native to the Mediterranean and Central Asia. Its berries have long been used for a variety of abnormalities including "corpus luteum deficiency," mastalgia (breast pain), and menstrual abnormalities. Although not studied clinically, chasteberry has been traditionally used for lactation. However, chasteberry is not recommended in breastfeeding women due to a lack of available scientific evidence. Chasteberry competitively binds to dopamine receptors and has been shown to affect prolactin secretion, possibly resulting in decreased breast milk production. However, some clinicians actually use low doses to stimulate milk production with some reported benefits.

• Avoid if allergic or hypersensitive to members of the Vitex (Verbenaceae) family or any chasteberry components. When taken in recommended doses, chasteberry appears to be well tolerated with few side effects. Use cautiously in patients taking oral contraceptives or hormone replacement therapy. Use cautiously with dopamine agonists or antagonists. Avoid with hormone sensitive cancers or conditions (like ovarian cancer or breast cancer). Except under strict medical supervision, chasteberry should not be used in pregnancy due to potential uterine stimulatory properties. Some clinicians have used chasteberry in progesterone deficient women during their first trimester to prevent miscarriage, but it is not known if chasteberry is helpful or safe for this indication.

• Dandelion: Dandelion (Taraxacum officinale) is a member of the Asteraceae/Compositae family closely related to chicory. It is a perennial herb, native to the Northern hemisphere, and found growing wild in meadows, pastures, and waste grounds of temperate zones. Although not studied clinically, dandelion has been traditionally used for breast milk stimulation.

• Dandelion should be avoided by individuals with known allergy to honey, chamomile, chrysanthemums, yarrow, feverfew, or any members of the Asteraceae/Compositae plant families (ragweed, sunflower, daisies). Use cautiously with diabetes or bleeding disorders, gastroesophageal reflux disease (GERD), kidney or liver diseases, or a history of stroke or electrolyte disorders. Potassium blood levels should be monitored. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures.

• Fennel: Fennel (Foeniculum vulgare) is native to the Mediterranean region. For centuries, fennel fruits have been used as traditional herbal medicine in Europe and China. Although not studied clinically, fennel has been traditionally used as a galactagogue (breast milk stimulant).

• Avoid in individuals with a known allergy or hypersensitivity to fennel or other members of the Apiaceae family including carrot, celery, and mugwort because of the chance of cross-sensitization. Oral allergy syndrome has been reported with the use of fennel in a woman. Allergic reactions affecting the skin, such as atopic dermatitis and photosensitivity, may occur in patients who consume fennel.

• Guided imagery: Therapeutic guided imagery may be used to help patients relax and focus on images associated with personal issues they are confronting. Experienced guided imagery practitioners may use an interactive, objective guiding style to encourage patients to find solutions to problems by exploring their existing inner resources. Biofeedback is sometimes used with imagery to enhance meditative relaxation. Interactive guided imagery groups, classes, workshops, and seminars are available, as well as books and audiotapes. Although not studied clinically, guided imagery has been traditionally used for increasing breast milk production.

• Serious adverse effects have not been reported in the available scientific literature. Theoretically, intense inward focusing may cause pre-existing psychological problems or personality disorders to surface. Guided imagery should not be relied upon as a sole therapy for potentially serious medical problems. Guided imagery is usually used as a supplemental technique to other treatments, not as a replacement.

• Guided imagery techniques should not be practiced while driving or during other activity requiring strict attention. Guided imagery may trigger physical symptoms that can be brought about by stress, anxiety, or emotional upset. If practicing guided imagery produces anxiety, a qualified healthcare professional should be consulted. Similarly, people with a history of trauma or abuse should speak with a healthcare professional before using this technique.

• Healing touch: Healing touch (HT) is a system of biofield- or energy-based therapy involving the practitioner's use of mental intention and the placement of hands in specific sequences either on the body or above it in the recipient's energy field. It also includes movement of the hands through the field to influence the flow or circulation of energy in a variety of ways. Although not studied clinically, healing touch has been traditionally used for promoting flow of breast milk.

• HT should not be regarded as a substitute for established medical treatments. Use cautiously if pregnant or breastfeeding.

• Hypnotherapy, hypnosis: Various forms of hypnosis, trance, and altered states of consciousness have played roles across cultures throughout history. Hypnosis-like practices can be traced to ancient Egypt, Babylon, Greece, Persia, Britain, Scandinavia, America, Africa, India, and China. Wong Tai, a father of Chinese medicine, made an early written reference to hypnosis in 2600 BC. In preliminary study, hypnosis has been investigated for its effects on lactation stimulation. Study results are conflicting at this time. Additional high quality clinical research is needed to make a conclusion.

• Use cautiously with mental illnesses, such as psychosis, schizophrenia, manic depression, multiple personality disorders, or dissociative disorders. Use cautiously with seizure disorders.

• Milk thistle: Milk thistle (Silybum marianum) has been used medicinally for over 2,000 years, most commonly for the treatment of liver and gallbladder disorders. A flavonoid complex called silymarin can be extracted from the seeds of milk thistle, and is believed to be the biologically active component. The terms "milk thistle" and "silymarin" are often used interchangeably. Milk thistle has been used historically to improve breast milk flow, and brief studies of milk thistle in pregnant women reported no side effects. However, there is not enough scientific evidence to support the safe use of milk thistle for lactation stimulation during pregnancy or breastfeeding at this time.

• Use cautiously if allergic to plants in the aster family (Compositea or Asteraceae), daisies, artichoke, common thistle, or kiwi. Use cautiously with diabetes. Avoid if pregnant or breastfeeding.

• Physical therapy: Although not studied clinically, physical therapy has been traditionally used for promoting flow of breast milk. Physical therapy has been used in pregnancy, specifically to treat women with pelvic girdle pain during pregnancy and at three, six, and 12 months postpartum.

• Reports of major adverse effects are lacking in the available literature, but caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation. Based on the available literature, physical therapy appears generally safe when practiced by a qualified physical therapist; however, complications are possible. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the physical therapy literature, although causality is unclear. Erectile dysfunction has also been reported.

• Raspberry: Raspberry (Rubus idaeus) is cultivated and grows wild throughout temperate climates, including North America and Europe. For several centuries, midwives have used raspberry leaf to stimulate and ease labor. Although not studied clinically, raspberry has been traditionally used as a galactagogue (breast milk stimulant).

• Raspberry leaf may induce labor. However, a clinical trial using raspberry leaf tablets reported no adverse effects. More study is needed in this area before a recommendation can be made. Avoid if allergic or hypersensitive to raspberry (Rubus idaeus), its constituents, or any members of the Rosaceae family. Use cautiously with asthma or if taking Clotrimoxazole, antibiotics (especially clarithromycin), antispasmodic agents or muscle relaxants, diuretics, salicylates, or laxatives, sedatives or operating heavy machinery. Cyclosporiasis associated with contaminated fresh raspberries has been reported. Always thoroughly wash raspberries before ingestion.

• Relaxation therapy: Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. The primary goal is usually non-directed relaxation. Most techniques share the components of repetitive focus (on a word, sound, prayer phrase, body sensation, or muscular activity), adoption of a passive attitude towards intruding thoughts, and return to the focus. Although not studied clinically, relaxation therapy has been traditionally used for increasing breast milk production.

• Avoid with psychiatric disorders such as schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, and then relaxing the muscles) should be used cautiously with illnesses, such as heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions and should not delay the time to diagnosis or treatment with more proven techniques.

• Therapeutic touch: The way therapeutic touch (TT) may affect the body is unknown. It is theorized that TT affects patients through the connection of energy fields within and outside of the body. Energy is thought to stimulate internal mechanisms to treat physical symptoms. The autonomic nervous system is felt to be particularly sensitive to TT, followed by the lymphatic, circulatory, and musculoskeletal systems. Female endocrine disorders are believed to be more sensitive than those affecting males. In preliminary study, therapeutic touch has been investigated for its effects on promoting flow of breast milk. Study results are conflicting at this time. Additional high-quality clinical research is needed to make a conclusion.

• Therapeutic touch is believed to be safe for most people. Therapeutic touch should not be used for potentially serious conditions in place of more proven therapies. Avoid with fever or inflammation, and on body areas with cancer.

• Turmeric: Although not studied clinically, turmeric has been traditionally used for increasing breast milk production (lactation stimulant). Clinical research is needed in this area to make a conclusion.

• Historically, turmeric (Curcuma longa) has been considered safe when used as a spice in foods during pregnancy and breastfeeding. However, turmeric has been found to cause uterine stimulation and to stimulate menstrual flow, and caution is therefore warranted during pregnancy. Animal studies have not found turmeric taken by mouth to cause abnormal fetal development. Avoid if allergic or hypersensitive to turmeric (curcumin), yellow food colorings, or plants belonging to the Curcuma and Zingiberaceae (ginger) families. Use cautiously with a history of bleeding disorders, immune system deficiencies, liver disease, or gallstones. Use cautiously if taking anticoagulants.

Self-Management

• Breast pumps: If a mother is breastfeeding her baby, a breast pump may offer flexibility. Breastfeeding is a round-the-clock commitment. That is why many breastfeeding mothers consider breast pumps very important. Breast pumps help express the milk from the mother's breast. Some breast pumps are hand-operated, others run on electricity, and the designs vary. Some models attach to only one breast while others let the mother express milk from both breasts at once.

• Choosing a breast pump depends on several factors. These factors include how often the breast pump is to be used. A simple hand pump works best on occasion, and an electric pump works best when a mother works full-time or is away from the baby for more than a few hours a day. Electric pumps stimulate the breasts more effectively than hand pumps. This helps empty the breasts and protect the milk supply. Electric breast pumps are faster than manual pumps. Double breast pumps allow pumping both breasts and help stimulate milk production while cutting pumping time in half.

• Every pump has a shield to place over the breast. If the mother is concerned that the standard breast shield is too small, check with individual manufacturers about other options. If the mother wants to pump both breasts at once, make sure the pump is equipped with two breast shields.

• Preparing and storing breast milk: When preparing breast milk, it is recommended by healthcare professionals to be sure to wash the hands before expressing or handling breast milk and when collecting milk, be sure to store it in clean containers, such as screw cap bottles, hard plastic cups with tight caps, or heavy-duty bags that fit directly into nursery bottles. Avoid using ordinary plastic storage bags or formula bottle bags, as these could easily leak or spill; if delivering breast milk to a child care provider, clearly label the container with the child's name and date; clearly label the milk with the date it was expressed to facilitate using the oldest milk first; do not add fresh milk to already frozen milk within a storage container as it is best not to mix the two; and do not save milk from a used bottle for use at another feeding.

• Thawing breast milk: As time permits, thaw frozen breast milk by transferring it to the refrigerator for thawing or by swirling it in a bowl of warm water. Healthcare professionals warn against using a microwave oven to thaw or heat bottles of breast milk as they do not heat liquids evenly. Uneven heating could easily scald a baby or damage the milk. Bottles may explode if left in the microwave too long. Excess heat can destroy the nutrient quality of the expressed milk.

• Breast milk can be stored at room temperature for four to eight hours (at no warmer than 77 degrees Fahrenheit, or 25 degrees Celsius). Breast milk can be stored in the refrigerator for up to eight days at 32-39 degrees Fahrenheit (0 to 3.9 degrees Celsius). Breast milk can be stored in the freezer: for up to two weeks in a freezer compartment located inside the refrigerator; for three to four months in a freezer that is self-contained and connected on top of or on the side of the refrigerator; or for six months or more in a deep freezer that is always 0 degrees Fahrenheit (-17.8 degrees Celsius). It is important to leave about an inch of space at the top of the container or bottle to allow for expansion of the milk when it freezes. If the breast milk is thawed, it can be refrigerated and used within 24 hours, but it is important not to refreeze it.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

1. American College of Obstetricians and Gynecologists. www.acog.org.

2. American Pregnancy Association. www.americanpregnancy.org.

3. Breslow RA, Falk DE, Fein SB, et al. Alcohol consumption among breastfeeding women. Breastfeed Med. 2007;2(3):152-7. View Abstract

4. Centers for Disease Control and Prevention. www.cdc.gov.

5. Hofmanova I. Pre-conception care and support for women with diabetes. Br J Nurs. 2006;15(2):90-4. View Abstract

6. Koletzko B, Cetin I, Thomas Brenna J; for the Perinatal Lipid Intake Working Group. Dietary fat intakes for pregnant and lactating women. Br J Nutr. 2007:1-5 [Epub ahead of print]. View Abstract

7. López Alvarez MJ. Proteins in human milk. Breastfeed Rev. 2007;15(1):5-16. View Abstract

8. Mai XM, Becker AB, Sellers EA, et al. The relationship of breast-feeding, overweight, and asthma in preadolescents. J Allergy Clin Immunol. 2007;120(3):551-6. View Abstract

9. National Women's Health Center. http://womenshealth.gov.

10. Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com.