What Evidence Do We Have for Pharmaceutical Galactagogues in the Treatment of Lactation Insufficiency?—A Narrative Review

Abstract

Inadequate breast milk supply is a frequently reported reason for early discontinuation of breastfeeding and represents a critical opportunity for intervening to improve breastfeeding outcomes. For women who continue to experience insufficient milk supply despite the utilisation of non-pharmacological lactation support strategies, pharmacological intervention with medications used to augment lactation, commonly referred to as galactagogues, is common. Galactagogues exert their pharmacological effects through altering the complex hormonal milieu regulating lactation, particularly prolactin and oxytocin. This narrative review provides an appraisal of the existing evidence regarding the efficacy and safety of pharmaceutical treatments for lactation insufficiency to guide their use in clinical practice. The greatest body of evidence surrounds the use of domperidone, with studies demonstrating moderate short-term improvements in breast milk supply. Evidence regarding the efficacy and safety of metoclopramide is less robust, but given that it shares the same mechanism of action as domperidone it may represent a potential treatment alternative where domperidone is unsuitable. Data on remaining interventions such as oxytocin, prolactin and metformin is too limited to support their use in clinical practice. The review provides an overview of key evidence gaps and areas of future research, including the impacts of pharmaceutical galactagogues on breast milk composition and understanding factors contributing to individual treatment response to pharmaceutical galactagogues.

The risk-risk trade-offs: Understanding factors that influence women’s decision to use substances to boost breast milk supply

“…For some women, ceasing breastfeeding earlier than initially desired leaves them feeling stigmatised [4] and can be a source of shame, grief, guilt, distress and anxiety [5,6], contributing to a reduced sense of agency to achieve breastfeeding goals and poor psychological wellbeing [7,8] One of the most common reasons cited for early cessation of breastfeeding is perceived low or insufficient milk supply [9][10][11][12]. This should be managed initially by the provision of breastfeeding counselling and support [13], however, when concerns persist, substances known as galactagogues are often recommended [13,14]. Galactagogues are foods, herbal supplements or medications believed to assist initiation, maintenance, or augmentation of breast milk supply [15].…”

Fenugreek Stimulates the Expression of Genes Involved in Milk Synthesis and Milk Flow through Modulation of Insulin/GH/IGF-1 Axis and Oxytocin Secretion

“…Prolactin stimulates the synthesis of main milk macronutrients by binding to its receptors located on the surface of lactocytes (milk secretory cells). Oxytocin stimulates milk ejection by inducing the contraction of myoepithelial cells surrounding mammary secretory alveoli [ 17 , 18 ]. Insulin also plays an essential role by stimulating mainly protein and lactose synthesis in the mammary gland [ 19 ].…”

Special foods and local herbs used to enhance breastmilk production in Ghana: rate of use and beliefs of efficacy

“…The GP Infant Feeding Network (UK), has also recommended its prescription in only exceptional circumstances [ 14 ]. The evidence base for pharmaceutical lactogogues such as domperidone and metoclopramide [ 15 ] is stronger than it is for herbal and food-based preparations where safety and concerns around insufficient study sizes have been raised [ 16 ]. While special herbs and food substances continue to be widely used in many settings around the world to enhance breastmilk production for centuries, evidence regarding their benefits or harms is largely absent.…”