Breastfeeding Medicine

Physicians blogging about breastfeeding

New Galactogogue Protocol–New Attitude??

with 8 comments

Today a new ABM protocol was published in Breastfeeding Medicine: ABM Clinical Protocol #9: Use of Galactogogues in Initiating or Augmenting the Rate of Maternal Milk Secretion (First Revision January 2011).    I am posting today having my hat on as ABM Protocol Committee Chairperson.  When we wrote the first version of this protocol in 2004, the basic message of the document was that galactagogues were a definite second-tier therapy for increasing milk supply, after all the mechanical and physical and otherwise treatable etiologies were investigated and adequately treated. That they are second-tier has not changed in this newest version.

What has subtly shifted is the attitude toward the use of the galactogogues themselves.  In 2004 there was an almost laissezfaire attitude—if the mechanical changes and medical work-up did not yield the hoped-for increased results in milk production, then galactogogues were effective, and thus should be, and were, used.  Although one should think (briefly) about potential side-effects, they were really quite rare, and the use of galactogogues were essentially (although not definitively stated as such) standard of care.  The protocol proceeded to tell us how to use them.

The 2011 revision gives us a different message.  It is a prime example of why protocols need to be reviewed, and revised, with all the blood, sweat and tears that involves for the primary contributors and for so many of us, every 5 years (or as you can see here, it often takes 6 for the process to be completed.)  In this case, the careful searching out and evaluation of interim evidence-based studies and emerging information regarding more serious potential side effects of some galactogogues resulted in a shift in the ABM’s recommendations regarding these drugs and herbs.  This newer data suggests that we should exercise more caution in recommending these drugs to induce or increase the rate of milk secretion in lactating women, particularly in women without specific risk factors for insufficient milk supply.  There have been more significant side effects documented for some of them.

We are also now using Levels of Evidence when stating recommendations.  The Levels of Evidence are based on the United States Preventive Services Task Force ‘‘Quality of Evidence’’  (last accessed February 12, 2011).  Each study reviewed is classified by the authors according to these Levels, and when a recommendation is made in the protocol, we give the Level of Evidence so that the reader has an idea how strongly the recommendation can/should be taken (e.g. Level I is a randomized, controlled study).  In this way, we feel we give you a better idea of how strong the recommendation is, based on how strong the data behind it is.

Consequently, as you read this revised protocol, you may be surprised to realize that the evidence for using pharmacologic and herbal galactagogues has grown weaker.  There are still some clinical situations that appear to warrant their use.  But there clearly also appears to be a knowledge gap, and yet another area ripe for research.  Check out the new protocol.  What do you think?

Kathleen Marinelli MD, IBCLC, FABM is a neonatologist a Board member of the Academy of Breastfeeding Medicine, and Chair of the ABM Protocol Committee.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Written by kmarinellimd

February 22, 2011 at 1:30 pm

8 Responses

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  1. I’m very happy to see this. Too often, galactogogues are turned to as a first-tier solution and the underlying causes of low supply are not discovered and the breastfeeding relationship declines in the long run. Or, if there is no low supply and a mother just needs encouragement and confidence, encouraging the use of drugs or herbs reinforces the idea that her body isn’t working, when there may be other factors at play. I hope that this protocol is taken to heart!


    February 22, 2011 at 2:44 pm

    • I love this response! I also wish people weren’t so quick to mention a milk enhancer. I feel it’s almost as bad as saying “well, you know not everyone can breastfeed. here’s some formula.” Either way you’re not actually helping with the problem or helping her learn what is normal.

      Monica Victor Colling

      June 24, 2013 at 1:18 pm

  2. Interesting to see this. I asked Jack Newman once at a conference why he prescribes domperidone so often to mothers with even a hint of milk supply troubles, and I expressed that it concerned me that mothers were getting the message they needed to rely on a drug rather than fix the underlying problem – and his reply was that protecting the milk supply and increasing the odds of the baby accomplishing full feeds at the breast was worth the risks of using drugs, and that it helps buy time to fix the underlying problems (if possible) while keeping baby at the breast, getting breastmilk.

    From my contacts with Canadian moms, most in the GTA area near Jack Newman, those who have actually been to his clinic get great support to address those underlying problems, but those who get domperidone prescriptions from their own doctors often don’t get the follow-up they need, and either end up on heavy doses long-term, or are unable to bring in a full supply with the dosage and duration of dom that their doctors prescribe.

    Rosemary @ LLL of Northampton

    February 22, 2011 at 5:08 pm

    • In my opinion (first author of the protocol), this gets to the heart of the matter. Six to ten years ago, there were many fewer of us working with these moms, and we WERE attentive to the underlying issues. We saw the preliminary evidence and were excited to have another option.

      Now, with the proliferation of people (lay counselors, LC’s and some physicians) who work with breastfeeding mothers, that certainly is no longer the case. I had a stronger sentence in my early drafts of the new protocol, but after editing for diplomacy (?) it ended up as “However, some providers may inappropriately recommend galactogogues prior to emphasizing the primary means of increasing the overall rate of milk synthesis (i.e., frequent feeding and complete milk removal at regular intervals) or evaluating other medical factors that potentially may be involved.”

      I will also say that I, personally, have recommended these drugs much less frequently over the past five years than I did previously.

      Nancy Powers, MD, FAAP, IBCLC, FABM

      March 16, 2011 at 7:32 pm

  3. I am delighted to see this protocol. Having taught hundreds of nurses across the country, I have heard too many interpret the ABM’s 2004 stance as implicitly endorsing galactogogues, and they have labeled me as “too conservative” because I am focused on the potential side effects. As with the use of any drug, it’s always a risk-benefit decision. The 2011 protocol gives a better understanding of risk/benefit.

    • Thanks Marie. We spent a LOT of time on this protocol, because we wanted to make sure we got it right. Nancy Powers did a lot of the revision work that got it to where it was in the shape it is now. As a committee we worked hard on this one (not that we don’t on all of them) and as Chair, I am very pleased and very proud of the work of my group. So thanks for taking the time to comment. Kathie Marinelli

      Kathie Marinelli

      March 15, 2011 at 11:39 pm

  4. […] about their use. As ABM Protocol Committee chairperson Kathleen Marinelli, MD, IBCLC, FABM notes, the basic message of the 2004 document was that “galactogogues were a definite second-tier […]

  5. […] ABM’s Protocol committee recently reviewed, evidence for medications to increase milk supply is weak, and must be balanced against concerns […]

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