Photo via Geekpharm used with permission.
Breastfeeding is entirely natural, yet can be exceptionally difficult for many new mothers. There is tremendous (unfounded) societal pressure to breastfeed, and many women feel guilty for struggling with the process, or not producing sufficient milk. Consequently, there is an entire industry dedicated to supporting and promoting breastfeeding. Today I want to focus on a single product, shown above, that represents much that is wrong in the way in which we support breastfeeding. The image is of what’s called a “breastfeeding supplement” which looks an awful lot like chocolate chip cookie, priced at whopping $21.99 for 20 cookies. The idea that a cookie can promote breast milk led me down a rabbit hole of research into supplement use in lactation, and the mercenary world where alternative medicine is routinely promoted without solid evidence of effectiveness or safety.
What is a galactagogue?
Galactagogue are substances that promote breast milk production (lactation). While no prescription drugs are approved solely to promote lactation, some drugs do have limited evidence to support galactagogue properties, and they are occasionally considered when women are not producing sufficient milk. However, clinical practice guidelines tend to support the use of galactagogues only after all other factors that may compromise breast milk production (e.g., latching difficulties, frequency of feeding) have been addressed. Diet is routinely thought to affect breast milk production, and every culture has its own food products that it believes support milk production. As per La Leche League, they include:
- Whole grains, especially oatmeal
- Dark, leafy greens (alfalfa, kale, spinach, broccoli)
- Fennel
- Garlic
- Chickpeas
- Nuts and seeds, especially almonds
- Ginger
- Papaya
- Spices like cumin seeds, anise seeds, fennel seeds, turmeric
Herbs as galactogogues
Herbal products have long histories of use across cultures, with lots of anecdotes, like foods, to support their use as galactagogues. Despite widespread use, research is lacking on these products, both in terms of their effectiveness, but also in terms of their safety to the mother and the infant. Given the possibility that any herbal supplement consumed will be passed through the breast milk to the baby, dual evaluations are necessary. Consequently, safety is a critical concern when considering herbs and supplements in women that are breastfeeding. As has been documented and discussed at this blog repeatedly, there is a lack of standardization and quality control in the dietary supplement industry and there is little enforcement (and no routine testing) to assure consumers that what is on the label is actually in the bottle. It is a buyer beware market, and one that requires cautious decision-making by breast-feeding women.
There are several reputable references on drug and supplement use in breastfeeding. While not all are online and freely accessible, I’ll summarize the evaluation from several sources as we look at the expected efficacy of these lactation cookies.
Cookies for lactation?
For some reason cookies to promote lactation have grown in popularity over the past several years. There are plenty of recipes online, and most seem to rely on household baking staples with some of the ingredients from the list above, like brewer’s yeast, flax, chickpeas, and oats. You can also find lactation brownies, lactation lemonade, and lactation lattes for sale online.
Digging into the product above, Upspring Milkflow, I found the following main ingredients:
- Enriched wheat flour
- butter
- sugar and brown sugar
- chocolate chips
- eggs
- 230 mg of a “Proprietary blend” of fenugreek seed extract (10:1) and blessed thistle extract (4:1)
Two cookies is 190 calories providing 6 grams of saturated fat, 25 grams of carbohydrate, and 2 grams of protein. Most of the ingredients are conventional cookie ingredients, with the exception of the two herbs. Let’s look closer at the effectiveness and safety of these products.
The evidence for fenugreek
The LactMed database is freely available online and probably the best open-access reference for information on drug and supplement use in lactation. Here is what it notes about fenugreek (Trigonella foenum-graecum):
Fenugreek (Trigonella foenum-graecum) seeds contain mucilage, trigonelline, 4-hydroxyisoleucine, sotolon, diosgenin, luteolin, phenolic acids, and protodioscin. Fenugreek has been used in a number of geographical regions worldwide as a galactogogue to increase milk supply and is included in numerous proprietary mixtures promoted to increase milk supply.[1][2][3][4][5][6][7][8] [9]The galactogogue effect of fenugreek may be primarily psychological.[10] Evidence for a galactogogue effect is mostly anecdotal. A limited number of published studies of low to moderate quality have found mixed results for a galactogogue effect for fenugreek.[11][12][13][14] A meta-analysis of controlled studies found fenugreek to have a mild galactogogue effect and unknown safety profile.[13] Some evidence indicates that fenugreek might be more effective in the first few days pospartum than after 2 weeks postpartum.[15] Some of these studies used a multi-ingredient combination products in which fenugreek was only one component, so the results might be different from studies in which fenugreek was used alone. Galactogogues should never replace evaluation and counseling on modifiable factors that affect milk production.[16]
Emphasis added.
Up-to-Date, which is a proprietary reference, notes the following on fenugreek:
Fenugreek is the most widely used herbal agent, but data are insufficient to determine its efficacy and safety [38-41]. Reported side effects include diarrhea, flatulence, allergic reactions, and hypokalemia. In addition, it is not known whether components of the herb are transferred to the infant via breast milk. As with all herbal supplements, manufacturers are not required to demonstrate efficacy, and the contents of individual products vary.
The Natural Medicines Database, another proprietary references, notes that fenugreek is “possibly safe” when used to stimulate lactation and that there is “Insufficient Evidence to Rate” in terms of its effectiveness when promoting lactation. It notes that while there is some evidence of effectiveness over placebo, some conflicting results have also been published.
The American Academy of Pediatrics, in a paper entitled, “Complementary, Holistic, and Integrative Medicine: Advice for Clinicians on Herbs and Breastfeeding“, notes the following on fenugreek:
Fenugreek (Trigonella foenum-graecum), a popular cooking spice in India and the Middle East, is traditionally used as a galactagogue to aid digestion. (14) Fenugreek is included in the Food and Drug Administration’s list of herbs generally regarded as safe. (15) Despite its wide popularity, there is little research on fenugreek and breastfeeding women.
And also:
Although fenugreek appears to have a good safety profile, particularly at doses typically used (3-6 g of powdered seed), its effectiveness as a galactagogue, optimal dose, and adverse effect profile in infants have not been established in clinical trials.
On balance, there is little evidence to establish the efficacy of fenugreek to support lactation. There is a long history of safe use of the product, but the safety profile has also not been closely evaluated.
The evidence for blessed thistle
This will be a much shorter summary, as there is very little published evidence on blessed thistle (Cardui benedicti) . The LactMed database entry is short and notes “no scientifically valid clinical trials support this use.” Up-to-Date has no information at all. The Natural Medicines Database notes “Insufficient reliable information available; avoid using” with respect to safety, and in terms of effectiveness for any clinical condition, simply “insufficient reliable information available”.
Cookies can be delicious, but probably won’t help with milk production
Women are understandably concerned when they have difficulty breastfeeding. Health professionals including lactation experts are the best resource for women experiencing challenges and can point to reputable resources online. While many foods and supplements are promoted to encourage breast milk production, there is very little evidence to suggest that these products are effective. Considering that breastfeeding is so widespread, this is frustrating to mothers and health professionals alike. It is important to note that, seeing a business opportunity, a large industry has developed that targets women at this vulnerable time. Products that are promoted to assist with lactation may not be supported by robust evidence of effectiveness or safety for either the mother or the infant.