Abstract
Support and promotion of breastfeeding are important healthcare issues and a global priority. In the United Nations Chronicle, it states that exclusive breastfeeding for the first 6 months is the ideal. In addition, timely and appropriate complementary feeding from 6 months of age and continued breastfeeding up to 2 years of age and beyond are also recommended. 1 Initiatives for promotion of breastfeeding have also led to the creation of international guidelines such as the strategies proposed by The National Institute for Health and Clinical Excellence 2 for the support of appropriate infant and young child feeding, especially in the first 2 years of life. However, lactation management protocols do not contain clear guidelines for the treatment of insufficient or deficient lactation.
Midwives play a key role in educating and supporting mothers regarding human lactation and infant feeding. Despite international efforts to promote breastfeeding, the management of insufficient lactation may differ among countries because of differences in health policies and legislation, as well as in midwife status. Sustainable breastfeeding depends on multiple physiologic and psychosocial factors. Early recognition of risk factors is critical for clinicians who interact with breastfeeding women so that intervention can take place and achievement of full or partial breastfeeding can be preserved. 3 Instruction and optimization of lactation techniques constitute primary interventions to maximize maternal lactation capacity. 4 When these techniques prove to be insufficient, different galactagogues such as medicinal plants/foods, homeopathy, or medication are sometimes recommended. No systematic studies have evaluated the safety or efficacy of lactogenic herbs/foods or homoeopathic remedies, although the traditional use of these plants suggests that they are relatively safe to use and may be effective. 5
We conducted a survey (a convenience sample), to analyze midwives' current practice for the initiation or augmentation of maternal milk supply in Switzerland and Canada. We used an online anonymous survey during March 2009 in both countries and collected the following information from participating midwives: Types of practices, number of breastfeeding women requiring use of galactogogues, treatment recommendations, and local or national management policies.
In Switzerland, 351 of 700 (50%) midwives and in Canada 80 of 175 (46%) completed the questionnaire. The majority of respondents (93% in Switzerland and 100% in Canada) reported their patients sometimes require the use of galactagogues, as well as the following: Instruction of breastfeeding techniques (100% in Switzerland and Canada), lactogenic herbs/foods (96% in Switzerland and Canada), homeopathy (46% vs. 4%), acupuncture (39% vs. 3%), and medication (16% vs. 68%). Only 14% of the respondents in Switzerland and 26% in Canada reported that they followed an official protocol or national guideline.
To our knowledge, this is the first study that attempts to provide an overview of current practices in this important field. Mothers report that insufficient milk supply is a reason for discontinuing breastfeeding, and our results confirm this. In our survey, recommended breastfeeding techniques, as suggested by the previously mentioned guidelines,1,2 were the preferred and first-line support advised by the respondents. Thus, international guidelines appeared to be applied to maximize maternal lactation capacity, although only a small percentage of respondents stated that they actually work with these protocols in everyday practice. When breastfeeding techniques were considered ineffective to correct insufficient lactation, a majority of the respondents from both countries recommended the use of galactagogues. It is interesting that many of the respondents from both countries considered, on an empirical basis, that herbal preparations as well as pharmaceutical compounds were effective in increasing lactation, which may explain why galactagogues were used on a fairly regular basis by the midwives. The galactagogues most frequently recommended by the Swiss respondents were lactogenic herbs/food, homeopathic remedies, and acupuncture (Table 1); Canadian respondents also recommended herbs/food but did not appear to be as familiar with homeopathic galactagogues or acupuncture, and domperidone was more often advised. Conversely, intranasally administrated oxytocin was the most frequently used medicinal galactogogue by the Swiss midwives.
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This study had several limitations, so caution should be used when interpreting the results. The midwives who participated in the study were not a randomized sample in either country, and the results may not be able to be extrapolated to other countries. The response rate was relatively low (less than 50%) in both countries, most likely reflecting a bias in participants, as individuals who completed the survey may have different opinions and practices than ones who declined participation. For example, midwives who declined to complete the survey may have been disinterested because they do not use galactogogues. Another limitation may have been because this survey was completed electronically, some individuals may have not felt comfortable using this model for participating in a survey. A further limitation was that there were more respondents from the Swiss group than the Canadians because more surveys were sent out in Switzerland as there are more practicing midwives in that country. Finally, this survey was undertaken more than 2 years ago, and there may have been changes in practice since then, although personal communication with midwives in both countries informed us that this is not so. However, we feel that it is an important pilot study and could be expanded with a larger sample of midwives in additional countries.
This survey provides an overview of interventions recommended by midwives for initiation, maintenance, or augmentation of maternal milk production in Switzerland and Canada. The overall practices for the management of insufficient milk appears to be appropriate, with the majority of respondents reporting they evaluated and corrected modifiable factors prior to use of galactogogues. However, it was very interesting to note that medication, foods, and herbal therapies were recommended as galactogogues, despite lack of scientific data evaluating the effectiveness and safety of most of these products. Furthermore, the type of galactogogues recommended differed between Switzerland and Canada, and this highlights the need for clinical trials to evaluate the risk/benefits of these products, so it will be possible to implement worldwide guidelines formulated with evidence-based information.