Survey of Lactation Instructors on Folk Traditions in Breastfeeding

Introduction

Women who choose to breastfeed are often bombarded with advice about how to do so successfully. With the proliferation of educational journals, support groups, and Internet sites, women have access to an increasing amount of information. Some is well researched and espoused by the medical community; some is rooted in folklore and passed on from generations of oral tradition. Although the latter advice may be innocuous or even humorous, some recommendations may have adverse effects. For example, many women are encouraged to drink beer in order to stimulate breastmilk production. ¹ Such advice recently became newsworthy when the singer Mariah Carey was accused of endangering her twins for following it. ² In another example, a Turkish survey found that 27% of postpartum women had been told to withhold breastmilk if the baby had diarrhea, which could possibly lead to more dehydration. ³

In the last survey to systematically collect information about American women's exposure to such advice, members of the La Leche League International were asked for recommendations that they had heard. ⁴ This information was collected over 35 years ago, and solicitation was made by mail. Now that the Internet has made such information easier to disseminate and collect, this study was repeated with an Internet-based survey of lactation experts similar to those in the La Leche League International study. The aim was to identify which folk practices are being discussed in the breastfeeding community and which have been adopted by lactation educators. By comparing instructors who espouse such advice and those who do not, the study also aims to identify characteristics that would make lactation instructors more likely to communicate folk traditions to their clients.

Materials and Methods

A questionnaire was constructed to elicit responses from lactation consultants regarding advice given to breastfeeding women. Although specific examples of folkloric recommendations were not given, the instructions specified that advice regarded as “old wives' tales” and outside of the medical mainstream were of interest. Respondents were asked to provide examples of advice that they had heard of as well as advice that they routinely passed on. Advice was broken down into five categories: recommendations to promote lactation, to initiate breastfeeding, to treat pain associated with breastfeeding, to assist with weaning, and about substances to avoid for the baby's sake. An open-ended question was also included to allow for input that was not covered under the above categories. Furthermore, basic demographic information was obtained including age, parity, experience as a lactation consultant, and education. Geographic and ethnic characteristics of the respondent's clientele were also asked.

An invitation to participate in the survey was sent to professional lactation consultants whose e-mail addresses were listed in the directory of the www.breastfeeding.com website, a popular resource for identifying lactation consultants. Invitations were sent only to those consultants who were affiliated with a hospital or academic program, as they were consistently credentialed with either an R.N., C.N.M., or R.N.C. degree and therefore felt to be more likely to use evidence-based protocols. The questionnaire was administered through a secure centralized online survey service that maintained the individual's anonymity and confidentiality. The Office of Responsible Research Practice at the Ohio State University determined that the study was exempt from Institutional Review Board review.

Responses for each category were tabulated using Microsoft Excel. The pool of participants who claimed to recommend any of the nontraditional methods listed was compared with those who did not in order to identify any characteristics associated with a greater likelihood of communicating these recommendations. Continuous variables were compared with Student's t test, and categorical variables were compared using contingency tables.

Results

Invitations to participate in the survey were sent to 293 lactation consultants in 46 states. One hundred twenty-four responses from 29 states were received, yielding a response rate of 42%. Of those lactation specialists who responded, 86 (69%) were familiar with at least one folk remedy, and 80 (65%) reported recommending one or more folk remedies to their clients.

Table 1 lists the types of folk therapies most often heard and recommended by participants. The greatest number of folk recommendations was made in the category of lactation promotion, with 72 (58%) recommending at least one tactic. The most common items recommended were fenugreek (57 respondents), blessed thistle or milk thistle (n=28), and oatmeal (n=17). Twelve recommended other herbal preparations (e.g., goat's rue, fennel, shatavari, nettle, “mother's milk tea”), and four each recommended beer or yeast.

Advice to prevent or relieve breast pain was included in 51 (41%) surveys. The most common of these was the application of cabbage leaves for pain (n=36). Ten consultants listed lanolin, which could be considered a mainstream remedy as well. Four recommended the use of tea bags, and one mentioned allowing colostrum to dry on the nipple.

Although 24 respondents indicated that they would advise against certain maternal ingestions while breastfeeding, they specified alcohol (n=14) and caffeine (n=12), which are arguably not folk traditions. Fifty-four consultants were familiar with the recommendation to avoid foods such as beans, cruciferous vegetables, and spicy foods to avoid infant gassiness or colic, although only two passed this advice along.

Folk recommendations for initiating breastfeeding and weaning were rarely made. The only responses that could be considered outside of the mainstream were use of milk and toughening of the nipples to get the infant to latch on and application of bitter herbs to the nipple to get the baby to wean. Three respondents recommended binding of the breast to facilitate weaning.

In Table 2, those consultants who had made any folk recommendations were compared with those who had not. There was no significant difference between these groups in relation to age, parity, education, time spent as a consultant, or the type of community in which consultation is made. Although most consultants reported catering to a socioeconomically diverse clientele, there was no difference in the socioeconomic status of clients between the two groups.

Discussion

The survey results suggest that recommending folk remedies is a common practice among lactation consultants who advise women about breastfeeding. Many of these practices are widespread, and there do not appear to be any characteristics of consultants that make them more likely to make such recommendations.

Despite the frequency with which such advice is given, there is little empirical evidence to support the use of most of the remedies listed, and the Academy of Breastfeeding Medicine does not recommend any pharmacologic or herbal galactogogues. ⁵ Galactogogues may be commonly prescribed because of the perceived need to augment the milk supply, but few traditional types have been tested. Fenugreek is commonly used, with reports of use in the medical literature dating back to 1945, ⁶ but positive clinical data have been mainly anecdotal. One review of galactogoguic therapies cites a single abstract that demonstrated a statistically significant improvement in breastmilk production when fenugreek was used in large amounts three times daily. ⁷ However, its use is not without risk, and it has been linked to asthma exacerbation and gastrointestinal symptoms, as well as a potentiating effect on other drugs such as anticoagulants and diabetic medications. ⁸ Other herbal remedies with purported benefit for breastfeeding women include goat's rue (galega), milk thistle (silymarin), anise, basil, fennel, mauve, verbena, cumin, and coffee. A single human study examining the effect of a micronized silymarin extract demonstrated a significant increase in milk production compared with a placebo. ⁹ No clinical data are available for the other herbs, although galega has been shown to increase milk production in cows. ⁷

Using beer to promote milk production is a folk tradition of long standing. Citations for this practice date back to 1879, and beer companies in the early 1900s marketed low alcohol beer to enhance women's yield of milk. ¹⁰ The rationale given is that components of barley can increase serum prolactin levels, but no systematic studies have demonstrated a positive effect on milk production. ¹ In fact, maternal alcohol consumption has been demonstrated to decrease milk production and may have adverse effects on the infant. ¹¹

Another remedy used to increase milk production mentioned in this survey was oatmeal. There are no studies that examine its use, but one review mentions that this folklore item is used in many cultures. ¹²

Folk traditions that aid with breast pain or engorgement were also popularly mentioned. The use of cabbage leaves is frequently recommended, although empirical studies have questioned their utility. They have been shown to be as effective in treating breast pain as hot or cold compresses applied to the breast, ¹³ and no difference was noted between applying the cabbage leaf warmed or cooled. ¹⁴ Using cabbage leaves does not prevent engorgement, either. ¹⁵ A Cochrane review of the literature on treatments for engorgement concluded that there is no strong evidence for use of this remedy. ¹⁶

Tea bags probably have the same effect as any moist compress. A randomized trial of breastfeeding women complaining of nipple soreness demonstrated a benefit of tea bags over no treatment but no significant difference from the use of a water compress. ¹⁷ A review of studies that examine treatments for nipple pain concluded that there was no significant benefit to the use of tea bags, lanolin, or expressed milk on the nipple. ¹⁸

Fewer lactation consultants proscribed particular foods while breastfeeding. Although 43.5% of the respondents were aware of recommendations against the ingestion of foods to produce infant gassiness, only two passed this advice along. A study of maternal intake of cruciferous vegetables, however, did indicate that colic symptoms were more likely in infants of mothers who ate cabbage, broccoli, and cauliflower, as well as cow's milk, onions, and chocolate. ¹⁹

The folk traditions that were communicated in this survey represent a particular culture, and folklore in general varies by culture and background. The current study surveyed a group of women who generally were well educated and geographically uniform in the sense that all were practicing in the United States. Surveys of breastfeeding women, or of lactation consultants, in different countries and of different ethnicities may yield different results and the description of other traditions not mentioned here.

This study was also limited by the fact that data collection was done by Internet survey and not in person. Although the goal was to make the explanatory text sufficiently clear to give the individual a sense of what is meant by “folk tradition,” many responses of a more mainstream nature suggested that participants were discussing all advice that was being given to their clients. In analyzing the data, the categorization of what constituted a folk tradition versus a mainstream cure was highly subjective. For example, recommending beer to increase milk production seems folkloric, but recommending against alcohol because of its effect on the infant seems more in line with medical practice. Future research may be more accurate if participants are given concrete options or have face-to-face interviews whereby the intent of the question can be more specifically explained.

Conducting the survey by Internet also introduced the possibility of selection bias. Those consultants who chose to respond may have a greater interest in the subject and may not be representative of the greater community of lactation consultants. Although the effort was made to target experts with good credentials and an academic affiliation, respondents did not specify their educational experience, and differing degrees of certification may have also influenced responses. Nevertheless, the large number of opinions solicited suggests that use of folk remedies by lactation consultants is common.

Conclusions

Folk traditions are commonly communicated in breastfeeding education, particularly when recommending methods to improve milk production or treat breast pain. There is no significant difference between practitioners who recommend folk remedies and those who do not. These experienced consultants often recommend therapies when there is little empirical evidence to justify their support. The frequency with which these recommendations are given suggests that further research is necessary to provide proof of efficacy and safety beyond anecdotal evidence.