Guideline:
Use of galactogogues in initiating or augmenting maternal milk supply
Bibliographic Source(s)
- Academy of Breastfeeding Medicine. Use of galactogogues in initiating or augmenting maternal milk supply. New Rochelle (NY): Academy of Breastfeeding Medicine; 2004 Jul 30. 5 p. [39 references]
Guideline Status
This is the current release of the guideline.
Guideline Category
Evaluation
Management
Treatment
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
- To facilitate optimal breastfeeding
- To provide recommendations on the use of galactogogues in initiating or augmenting maternal milk supply
Target Population
- Women who are adoptive nursing
- Women who need assistance with initiation maintenance or augmentation of maternal milk production
Interventions and Practices Considered
Evaluation
- Assessing patient for indications for galactogogues (adoptive nursing relactation increasing declining milk supply)
- Screening for contraindications
- Evaluation of current maternal milk supply and effectiveness of milk transfer
Management/Treatment
- Informing patient regarding the efficacy safety and timing of use of galactogogues
- Follow-up of mother and infant
- Galactogogue use
Major Outcomes Considered
- Maternal milk supply
- Adverse events associated with treatment
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
An initial search of relevant published articles written in English in the past 20 years in the fields of medicine psychiatry psychology and basic biological science is undertaken for a particular topic. Once the articles are gathered the papers are evaluated for scientific accuracy and significance.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Levels of Evidence
I Evidence obtained from at least one properly randomized controlled trial
II-1 Evidence obtained from well-designed controlled trials without randomization
II-2 Evidence obtained from well-designed cohort or case-control analytic studies preferably from more than one center or research group
II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.
III Opinions of respected authorities based on clinical experience descriptive studies and case reports; or reports of expert committees
Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence
An expert panel is identified and appointed to develop a draft protocol using evidence based methodology. An annotated bibliography (literature review) including salient gaps in the literature are submitted by the expert panel to the Protocol Committee.
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation
Draft protocol is peer reviewed by individuals outside of lead author/expert panel including specific review for international applicability. Protocol Committee's sub-group of international experts recommends appropriate international reviewers. Chair (co-chairs) institutes and facilitates process. Reviews submitted to committee Chair (co-chairs).
Draft protocol is submitted to The Academy of Breastfeeding Medicine (ABM) Board for review and approval. Comments for revision will be accepted for three weeks following submission. Chair (co-chairs) and protocol author(s) amends protocol as needed.
Following all revisions protocol has final review by original author(s) to make final suggestions and ascertain whether to maintain lead authorship.
Final protocol is submitted to the Board of Directors of ABM for approval.
Major Recommendations
Indications for Galactogogues
Common indications for galactogogues are adoptive nursing (induction of lactation in a woman who was not pregnant with the current child) relactation (reestablishing milk supply after weaning) and increasing a faltering milk supply because of maternal or infant illness or separation. Mothers who are not directly breastfeeding but are expressing milk by hand or with a pump often experience a decline in milk production after several weeks. One of the most common indications for galactogogues is to augment a declining milk supply in mothers of preterm or ill infants in the neonatal intensive care unit.
Procedure
- Before using any substance to try to increase milk supply a full evaluation of current maternal milk supply and effectiveness of milk transfer is imperative. Attention must be directed to the evaluation and augmentation of frequency and thoroughness of milk removal. This can be accomplished through increased frequency and duration of breastfeeding (if the infant has been shown to be effective at emptying the breasts) or pumping. A full-size automatic cycling breast pump capable of draining both breasts ("hospital grade") at the same time is recommended if available. Problems such as inappropriate timing and duration of feedings inappropriate supplementation mother-infant separation ineffective latch and inadequate milk transfer should be corrected.
- Women should be informed of any data (or lack thereof) regarding the efficacy safety and timing of use of galactogogues. With the exception of adoptive nursing where galactogogues are started before the birth of the baby there is no research to suggest that starting galactogogues within the first week postpartum is efficacious.
- Mothers should be screened for contraindications to the chosen medication or substance and informed as to possible side effects. Although a lactation consultant may recommend the medication or herb it is the physician's responsibility to prescribe medications and follow the mother and infant.
- The physician who prescribes the medication is obligated to follow or to ensure appropriate follow-up of both mother and infant regarding milk supply and any side effects. In practice many times it is the nurse practitioner pediatrician or neonatologist who is asked to prescribe a galactogogue and not the obstetrician-gynecologist. As is commonly found when dealing with lactation family physicians are ideally situated to manage this issue.
- Although short-term use (1 to 3 weeks) has been evaluated for some of these substances long-term use has not been studied. Anecdotal reports suggest no increase in side effects with the most commonly used medications (metoclopramide domperidone fenugreek) but long term effects on both mother and infant are unknown.
Specific Galactogogues
Many medications foods and herbal therapies have been recommended as galactogogues (see the section titled "Specific Galactogogues" in the original guideline document for information on metoclopramide domperidone sulpiride chlorpromazine human growth hormones thyrotrophin-releasing hormone and herbal/natural galactogogues). The medications used often exert their effects through antagonism of dopamine receptors resulting in increased prolactin. In many cases the mechanism(s) of action are unknown.
Conclusions
Of the substances used to induce maintain or augment milk production domperidone and metoclopramide appear to be the most clinically useful. Prior to the use of any galactogogue evaluation and correction of any modifiable factors such as frequency and thoroughness of breast emptying should be addressed. Medication should never replace evaluation and counseling on modifiable factors or reassurance when appropriate. As with any medication given to lactating women close follow-up of both mother and baby is essential.
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of evidence supporting the recommendations is not specifically stated.
The recommendations were based primarily on a comprehensive review of the existing literature. In cases where the literature does not appear conclusive recommendations were based on the consensus opinion of the group of experts.
Potential Benefits
Appropriate use of galactogogues for initiating or augmenting maternal milk supply
Potential Harms
Side effects of medications
Contraindications
- Metoclopramide should not be used if patients have epilepsy or are on antiseizure medications have a history of significant depression or are on antidepressant drugs have a pheochromocytoma or uncontrolled hypertension have intestinal bleeding or obstruction or have a known allergy or prior reaction to metoclopramide.
- Domperidone is contraindicated in patients with known sensitivity to the drug and in situations in which gastrointestinal stimulation might be dangerous (e.g. gastrointestinal hemorrhage mechanical obstruction or perforation).
Qualifying Statements
A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Foreign Language Translations
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- Academy of Breastfeeding Medicine. Use of galactogogues in initiating or augmenting maternal milk supply. New Rochelle (NY): Academy of Breastfeeding Medicine; 2004 Jul 30. 5 p. [39 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
Academy of Breastfeeding Medicine
A grant from the Maternal and Child Health Bureau US Department of Health and Human Services
Guideline Committee
Academy of Breastfeeding Medicine Protocol Committee
Composition of Group that Authored the Guideline
Committee Members: Caroline J. Chantry MD FABM Co-Chairperson; Cynthia R. Howard MD MPH FABM Co-Chairperson; *Anne Montgomery MD FABM; *Nancy Wight MD FABM
* Lead author(s)
Financial Disclosures/Conflicts of Interest
None to report
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the Academy of Breastfeeding Medicine Web site.
Print copies: Available from the Academy of Breastfeeding Medicine 140 Huguenot Street 3rd floor New Rochelle New York 10801.
Availability of Companion Documents
The following is available:
- Procedure for protocol development and approval. Academy of Breastfeeding Medicine. 2007 Mar. 2 p.
Print copies: Available from the Academy of Breastfeeding Medicine 140 Huguenot Street 3rd floor New Rochelle New York 10801.
A German translation of the original guideline document is available from the Academy of Breastfeeding Medicine Web site.
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI Institute on November 1 2007. The information was verified by the guideline developer on December 2 2008.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.
Single copies may be downloaded for personal use. Copyright permission to be requested for use of multiple copies by e-mailing requests to abm@bfmed.org. An official request form will be sent electronically to person requesting multiple copy use.
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