By Tieraona Low Dog, MD, and Adriane Fugh-Berman, MD
Lactating women have used plants to increase milk production, treat complications of lactation (sore nipples, mastitis), and decrease breast engorgement for centuries. Herbs used to increase milk flow are called galactagogues or lactagogues. Commonly used lactagogues include blessed thistle (Cnicus benedictus), borage leaves (Borago officinalis), goat’s rue (Galega officinalis), fennel (Foeniculum vulgare), fenugreek (Trigonella foenum-graecum), chaste-tree berry (Vitex agnus-castus), vervain (Verbena officinalis), nettles (Urtica dioica), and raspberry leaves (Rubus strigosus).1,2 Mixtures of these herbs are common.
No clinical trials of herbs for inducing lactation were identified. Fennel is commonly used in foods and is benign; nettles and raspberry leaves also are harmless. Fenugreek is used extensively as a lactagogue and there are no reports of adverse effects found in the literature.3 The taste and odor of fenugreek are similar to maple syrup and this odor can be imparted to the urine. In children, this may mistakenly lead a practitioner to consider the diagnosis of maple syrup urine disease, or branched-chain hyperaminoaciduria, a rare, inherited metabolic disorder. This should be kept in mind, as fenugreek commonly is used as a lactagogue in the United States.
Chaste-tree berry (Vitex agnus-castus) is used as a lactagogue, although it decreases prolactin levels in humans4,5 (it seems as though it should have the opposite effect). One animal study demonstrated a reduction of milk production and increased mortality in suckling rats when chaste-tree berry was administered to the mothers;6 another study demonstrated a lactogenic action with no change in chemical composition of breastmilk.7 Lactogenic activity may be related to dose. An open placebo-controlled study of 20 healthy males found that thyrotropin-releasing hormone-stimulated prolactin secretion increased with the 120 mg dose and decreased with the 480 mg dose.8 Interestingly, the manufacturers of Agnolyt®, the most extensively studied German chaste-tree product, contraindicate its use during lactation.9
No serious adverse effects have been associated with chaste-tree berry, although symptoms reported in clinical trials include gastrointestinal symptoms, dermatological reactions (acne, skin rashes, urticaria), and menstrual cycle changes.10
Goat’s rue is a traditional lactagogue and hypoglycemic herb used in Europe and South America. Gillet-Damitte presented the herb to the French Academy in 1873 with the observation that goat’s rue increased milk production in cows by 35-50%. Remington later confirmed its lactogenic activity in 1913.11 There have been no controlled human trials to establish its lactogenic activity in nursing women.
The use of borage leaves should be discouraged; borage leaves contain unsaturated pyrrolizidine alkaloids, which have been associated with hepatotoxicity.
Maternal ingestion of a lactation tea containing extracts of licorice (Glycyrrhiza glabra), fennel, anise, and goat’s rue was linked to drowsiness, hypotonia, lethargy, emesis, and poor suckling in two breast-fed neonates; an infection work-up was negative and symptoms and signs resolved upon discontinuation of the tea (and a two-day break from breastfeeding).12 Non-specific symptoms (drowsiness and weakness) also were reported by one of the mothers. Anise is widely used in both children and adults and is considered safe, and the other herbs in this tea would not be expected to cause these effects. It is possible that this tea contained a contaminant, an adulterant, or a misidentified herb. Interestingly, goat’s rue is known to be toxic to sheep at doses as low as 0.8 g/kg; however, the animals quickly adapt to the plant and can subsequently consume doses up to 10 times this amount after repeated exposure.13
Herbs to Decrease Breast Milk Production
Herbs purported to decrease milk production include sage (Salvia officinalis), peppermint (Mentha piperita), and bugleweed (Lycopus europaeus). Peppermint is benign. Sage contains thujone, the neurotoxic component of absinthe; although thujone is inactivated by heat, it is unknown what levels of thujone are in sage tea. Sage tincture would not be recommended if a woman is still nursing. On rare occasions, extended therapy with high doses of bugleweed has resulted in enlargement of the thyroid. Sudden withdrawal of the herb can precipitate an increase in thyroid function.14 Oral administration of L. europaeus extract caused T3 levels to decrease for more than 24 hours, presumably as a consequence of reduced peripheral T4 deiodination. Luteinizing hormone and thyroid-stimulating hormone were significantly decreased in spite of reduced T4 and T3 levels, indicating activity at the hypothalamic or pituitary level.15 Due to hormonal effects, bugleweed is probably best avoided by lactating mothers.
Although prevention is key for avoiding the development of sore nipples, several herbs commonly are recommended by herbalists and naturopathic physicians. Calendula (Calendula officinalis) ointment is one of the most popular for chafed nipples. In vitro data demonstrate that the polysaccharides in calendula stimulate phagocytosis; aqueous and alcoholic extracts have been shown to stimulate epithelialization in surgical wounds in vivo. The herb is bactericidal to Staphylococcus aureus.16 There are no clinical trials evaluating the effectiveness of calendula ointment for chafed nipples, but there are no reports of adverse effects when topically used by lactating women.
Persistently cracked, sore nipples may indicate the presence of a Candida infection. Tea tree oil (Melaleuca alternifolia) often is recommended in the lay literature. Tea tree oil has been used for centuries in Australia for the treatment of wounds. There are no clinical trials in nursing women to determine its use for candidal mastitis, but in vitro research indicates that the essential oil has excellent coverage against Candida spp.17,18 One clinical trial found it to be effective for fluconazole-resistant oral thrush.19 Essential oils can be toxic when taken in large doses internally, so breastfeeding mothers should rinse the breast prior to nursing.
Herbs for Breast Engorgement
Topical application of cabbage leaves was tested in a randomized, controlled, open trial conducted in Johannesburg, South Africa.20 One hundred twenty breastfeeding women, 72 hours postpartum, were randomized to application of cabbage leaves to their breasts or routine care. Of the 132 women who were approached, 12 chose not to participate because they believed that cabbage leaves relieve engorgement and did not want to be assigned to a control group. Holes were cut in the cabbage leaves so that the nipples would not be covered. The leaves were kept in the refrigerator and applied cold after four feeds; the leaves were kept in place until they reached body temperature (approximately 20 minutes). Mothers assessed their own level of breast engorgement by completing questionnaires prior to the next four feeds (after treatment), and also completed a questionnaire six weeks postpartum. Perception of breast engorgement and frequency of feeding did not differ significantly between the treated and control groups. The only statistically significant difference between the groups was in duration of breastfeeding, which was longer in the treated group than in the control group (36 vs. 30 days, P = 0.04).
A Cochrane review of three other trials using cab-bage leaves and/or cabbage leaf extracts concluded that the treatment failed to demonstrate superiority over placebo.21
Topical applications of jasmine flowers (Jasminum sambac) are traditionally used in South India to suppress lactation. Sixty women in Vellore, India, whose babies were stillborn or died within 24 hours of birth, were randomized to bromocriptine 2.5 mg every eight hours for five days or jasmine flowers (strung on a 50 cm string), apparently taped to each breast.22 Flowers were replaced daily for five days. Paracetamol (acetaminophen) was allowed for breast pain. Prolactin levels were taken 24 hours after delivery and after 72 hours of treatment. Breast engorgement was assessed on a 4-point scale, and milk production was evaluated by manual pressure. Prolactin levels fell in both groups but were significantly lower in the bromocriptine group compared to the jasmine group. Lactation scores were similar between groups after 72 hours of treatment. Bromocriptine failed to suppress lactation in one woman and jasmine flowers failed in two. Two women receiving bromocriptine had rebound lactation at two-week follow-up. Consumption of analgesics was similar between groups. This study would have been improved by use of a placebo group.
In lactating mice, topical contact with jasmine flowers inhibited milk production and caused regressive changes in breast parenchyma.23
Most herbs used for inducing lactation are benign; internal use of borage leaves, bugleweed, or uncooked sage should be discouraged. Clinical trials do not support topical application of cabbage leaves for breast engorgement in lactating women, but one clinical trial does support the use of topical jasmine for treating engorgement in women who want to suppress lactation. Calendula preparations are a benign treatment for sore nipples, and tea tree oil is a benign treatment for a candidal infection, but care should be taken to avoid ingestion of tea tree oil by an infant.
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