This document discusses induced lactation from Islamic perspectives, protocols for induced lactation, and the effects of galactogogues. It notes that Islam permits adoptive mothers to induce their own lactation with medical assistance. It describes the Newman Goldfarb Protocol, which uses medications and pumping to induce lactation. It discusses the effects of hormones like prolactin and oxytocin on breast milk production. It provides details on regular, accelerated, and menopause protocols for induced lactation using medications. It also discusses the use of galactogogues like herbs and medications to increase milk supply and notes potential risks and lack of research on many galactagogues.

1. CME Induced lactation
Wong Hui Juan (Jess)
Nutritionist, IBCLC

2. Overview
• Induced lactation from islamic perspectives
• Protocols
• Effect of galactagogues
• Supplementary feeding devices

3. Induced lactation from islamic
perspectives
• Muzakarah- 96 (2011)
– Islam membenarkan wanita yang tidak melahirkan
anak tetapi mengambil anak angkat menyusukan
sendiri anak tersebut dengan bantuan perubatan
– Pandangan jumhur ulamak, hambali, Syafi’e dan
Hanafi yg menyatakan seorang perempuan yang
hendak menyusukan tidak diisyaratkan
mempunyai suami
– Penggunaan ubtan dan suntikan utk merangsang
pengeluaran susu adalah harus

4. Tujuan dan matlamat penyusuan Ibu
Pemakanan
bayi
Susu ibu yg
terbaik
Untuk 6 bulan
secara eksklusif
Diteruskan
sehingga 2 tahun
Hubungan
Status Mahram
5 kali penyusuan
Susu yang dihisap
mestilah sampai
ke perut bayi
Umur bayi tidak
lebih 2 tahun
(qamariah)

6. The Newman Goldfarb Protocol
• Developed in 1999
• For surrogacy or adoptive mother
• Medications and pumping
• Reduces the need for supplementation
• Derived from Lenore’s own experience with
induced lactation and that of 500 women that
she and Dr Newman have followed

7. Effect of hormones on breast
• Estrogen: stimulates the ductal epithelial cells
• Progesterones: induced duct formation
• Prolactin: complete lobulo-alveolar
development. It stimulates milk production
• Oxytocin: milk ejection reflex
• Human placenta lactogen, growth factor,
insulin etc

8. Regular
AcceleratedMenopause

9. Regular protocol
• The longer the mother can be on her
particular protocol, the more milk she will end
up with
• For surrogacy or adoptive mothers with a long
lead time
• Six months and longer

10. • 1 week: COCP each day + 10mg domperidone 4x/day
• 2nd week till 6months: continuous COCP and
domperidone 20mg 4x/day
• Alternatives: T. provera 2.5mg OD/ T. prometrium
100mg OD
• Stop COCP and continue with domperidone 6weeks
before baby is due
• No pumping or herbs until 6weeks before the baby is
due
• Slowly decrease the domperidone once mother’s milk
supply is well established

11. Accelerated protocol
• Suitable for adoptive mother or intended
mothers who have little time to prepare , or
for mothers who wish to relactate
• Milk production may be significantly lower

12. • COCP + domperidone 20mg QID for 30-60
days
• Alternative: t. provera
• If significant breast changes occur within 30
days, stops the birth control pill while
maintaining the domperidone and pumping
schedule begins
• Significant breast changes: increased in breast
size and feel full, heavy and painful

13. Menopause protocol
• Menopausal d/t surgical removal of her
reproductive organs or naturally occuring
menopause
• A women does not need a uterus or ovaries in
order to breastfeed
• Breasts and functioning pituitary

14. • COCP + domperidone 20mg QID for 30-60
days
• Alternative: t. provera
• If significant breast changes occur within 30
days, stops the birth control pill while
maintaining the domperidone and pumping
schedule begins
• Significant breast changes: increased in breast
size and feel full, heavy and painful

15. What to do if the mother does not
experince significant breast changes
• If not significant changes after 15 days-
Consider to increase progesterone intake
• Yasmin ( 3 times the amount of progesterone )
• Microgestin ( third more progesterone than in
the 1/35 pills)
• Adding T. provera 1.25mg

16. EFFECT OF:
MEDICALCONDITIONS,
MEDICATIONS,
HERBS/GALACTAGOGUES

17. What supportsOptimal lactation?
 Normal breast anatomy
 Intact neuroendocrine reflex
 Good general health and
nutritional status
 Effective support system

18. Neuroendocrine Reflex

19. Neuroendocrine Reflex
 Therelease and production of prolactin isdependent
onthe inhibition of a factor
Prolactin inhibitor factor,
produced by the hypothalamus,and dopamine-releasing
neurons.
 Activation of dopamine receptors onprolactin-secreting
cellsinhibits the release of prolactin.
 Prolactin regulates the volumeof milk produced
 Oncelactation isestablished
infant demand drives the process.
Inthe absenceof suckling,lactation ceasesin 2 to 3 week

20. NutritionDuring Lactation
 No special food or drinks
 Generally healthy well balanced diet
 Drink fluids to thirst
 Adequate protein and calories
 *Calcium
 *Multivitamin supplement

21. GALACTAGOGUES

22. What are Galactogogues?
 Substancethat aid in initiating and
maintaining adequate milk production.
 FromGreekword:
Galact - Milk
Agogos - Leading
 2 broad categories:
Synthetic
Herbal/Natural

23. Mechanismof action
 Poorly understood, inherentdifficulties of
researching
 Mostexert their pharmacologic effects through
interactions with dopamine receptors
increased prolactin levels
augmenting milk supply

24. Isthere a role?
 May be usefulfor womenwhoare unable to
produce breast milk ontheir owndueto:
infant prematurity
Illness of themotheror child,
adoption, or
surrogate motherhood.

25. PointstoConsider
 Thereare manyreasonswhy a mother’smilk supply
might be low.
 Need to evaluate and address underlying factors
 TheAcademy of Breastfeeding Medicine protocol on
galactogogues says:
 Prior to the useof a galactogogue
thoroughevaluation shouldbe performed of the entire
feeding processby a lactation expert.
Reassurancemaybe offered, if appropriate.
When intervention isindicated, modifiable factors
shouldbeaddressed

26. Modifiable factors
Medication shouldnever replace evaluation and
counselingonmodifiable factors
comfort and relaxation for the mother,
frequency and thoroughnessof milk removal
correcting positioning and attachment
correcting suckling difficulties
expressing milk after feedings to
increase supply
underlying medical conditions.

27. Synthetic Galactogogues
 Many pharmacologic agents
 2 mostcommonand lessadverse events:
Metoclopromide
Domperidone

28. Metoclopramide
 majority of published clinical data evaluating the useof
drug therapy for breast milk production
 promoteslactation by antagonizing the release of
dopamine in the central nervous system.
 Alsostimulates the upper gastrointestinal tract through a
similar mechanism
 Indication:
symptomatic treatment of gastroesophageal reflux
diabetic gastroparesis, and
prevention and treatment of nauseaand vomiting
associated with pregnancy, chemotherapy and postsurgical
situations

29. Metoclopramide
 Doseresponserelationship for improved lactation
Daily dosesof 30 and 45 mgof metoclopramide resulted in
significant increasesin serumprolactin levels and milk yield,
45 mgdaily doseproduce a faster onsetof effect
 Effective and safe therapy for the initiation and
maintenanceof lactation: 10 mgorally 3 timesaday
 Maternal side effects observed during therapy:
diarrhea and nervousness
Cancauseextrapyramidal sideeffects
 Remainsasthe galactogogue of choice
due to its documentedrecord of efficacy
and safety in womenand infants.

30. Domperidone
 also a dopamine antagonist
 Indication: treatment of chronicpostprandial
dyspepsia, reflux esophagitis, and emesis
 Dosesusedfor inductionand maintenanceof
lactation:
10 to 30 mg3 timesdaily
 exerts pharmacologic effects in
the periphery rather than centrally

31. Domperidone
 RCTshowseffective and safe methodof inducing
lactation during short-term use
 lesslipid soluble,hasa larger molecularweight
and haslower protein binding
limited amountof the drug crossesthe blood-
brain barrier
reduced extrapyramidal side
effects.
Decreasedrisk of toxicity to
both motherandinfant
 anattractive alternative

32. Other drugs
 Traditional antipsychotics:
sulpiride andchlorpromazine
 Humangrowthhormone
 thyrotrophin-releasing hormone
 Oxytocin
adverse eventslimit their use.

33. Natural Galactogogues
 Herbs
Culinary
Non Culinary
 Little researchonmostcommon
herbal preps
Animal vsHumanstudies
In vitro vsin vivo studies
 Mostare anecdotalreports

34. Natural Galactogogues
 Almostevery culture hassomesort of herb or plant or
potion to increasemilk supply
 Quite possible that herbal remedies help increase
milk supply.
someplants and herbsmight contain similar
pharmacological agentsasdrugs
that increasemilk supply
 Note that evenherbscanhave
side effects, evenserious ones.

35. Herbs: Culinary
 Fenugreek
 Anise
 Basil
 caraway
 Fennel
 Brewer’s yeast

36. Fenugreek
 Mostanecdotal useof the herb in at
least 1200 women
Anecdotal reports of the successfuluse
asa galactogogue havebeen
documentedasfar back as1945.
Formalpublished clinical data lacking
 doseasa galactogogue: 2 to 3 capsules3 times
daily (Max: 6g/dy)
 Theamountof fenugreek in eachcapsulemayvary
from batch to batch

37. Fenugreek
 Specific mechanismof action unknown
may affect breast milk production by stimulating sweat
production, and the breast isa modified sweat gland
 Somereported adverseevents
maple-like odor to urine and sweat
Diarrhea
aggravation of asthmatic symptoms.
 Contraindicated in pregnancy due to
uterostimulant effects

38. Herbs:Non Culinary
 Blessed thistle
 Chasteberry
 Red Clover
 RedRaspberry
 goat’s rue
 Black Cohosh

39. Reasonswhy should notberoutine advice
1.May cause side effects for mother,baby, or both.
 for example: Fenugreek
caninterfere with the absorption of medication,
vitamins,minerals, etc., whichcould evenworsenthe
underlying factors
cancausehypoglycaemia
cancauseGI upsetin baby and mother
thosewhohaveallergies to other legumes,suchas
peanuts,mayexperience cross-reactions

40. 2.Qualityandquantityofherbalpreparationsis not
consistent
 not regulated
 Potencyvarieswith different manufacturers
 Dosagemaynotbe corrector thesameeachtime
 Little info ontherapeutic dosagefor lactation

41. Reasonswhy should notberoutineadvice
3.Galactogogues cost money and time
 Mostpricesare marked-up e,g “lactation cookie”
 Herbal preps mustbe sourced
time would be better spenton
an extra nursingsessionor some
self-care

42. Reasonswhy should notberoutineadvice
3.Suggesting use of galactogogues reinforces the
idea thatspecial food is needed for breastfeeding
 underminesa mother’sconfidence in her ability to
breastfeed.
 Need to reinforce:
breastfeeding isthe normal way to
feed a human baby,
nospecial gadgets or diets required.

43. SUPPLEMENTARY
FEEDING DEVICES

44. SNS – REASONS &INDICATIONS
• At initial phase of induced lactation program
- Stimulation
- Toensure baby able to latch on the breast
(baby know that milk ispresent)
- Toensure baby feeling satiety
- Prevent nipple confusion
- BONDING

45. • At maintenance phase (after milk has been produced)
- Maintain stimulation
- Adherence to the breast
- Prevent breast rejection / refusal
- Maintain BONDING
- Prevent blocked ducts
- Toensure successful milk production – adequate &
achievement of MAHRAM status
SNS – REASONS &INDICATIONS

46. Supplementary NursingSystem

48. OTHER TYPES -SIMPLE

49. FEEDING ON SNS :
TIME MANAGEMENT
CAN FEED ANYWHERE
& ANYTIME
PROPER PREPARATION

50. PSYCHOLOGICAL
• NEW MOTHERS – UNABLE TO COPE WITH BABY’s BEHAVIOUR
(CRYING, SLEEPING & etc) & HOUSEHOLD CHORES
• MOTHER - ANXIETY & STRESSFUL
• NOT MENTALLY PREPARED TO BE A MOTHER
• NON SUPPORTIVE SPOUSE & FAMILY MEMBERS
• TIME CONSUME FOR PREPARING SNS EQUIPMENTS LONGER
THAN PREPARATION OF BOTTLE FEEDING
• NOT ENOUGH TIME – TO PUMP & USING SNS
• WORKING MOTHER - NOT CONDUCIVE WORKPLACE
ANTICIPATINGPROBLEMS

51. ANTICIPATINGPROBLEMS
DEVICES – SNS EQUIPMENTS
• BLOCKED TUBES
• TUBES – BROKEN
• PREPARING SNS – SIMILAR TO COMPLETE THE PUZZLE OF
MULTIPLE PARTS - INCORRECT & CONSUME LOTS OF TIMES
• MAINTAINING HYGIENE, STERILITY & CLEANING PROCESS
• BABY REJECTION – FEELING UNCOMFORTABLE WITH THE
PRESENCE OF TUBE
• BABY POSITION – MAY PULL THE TUBE / KINKING THE TUBE

52. SUPPLEMENTARY FEEDINGDEVICES
• COUNSELORS & MOTHERS NEED TO FAMILIARIZE WITH THE
DEVICE COMPONENTS
• NEED TO KEEP PRACTICE ON HOW TO USE & HANDLE SNS
• MAY NEED MORE DEVICES OR EMERGENCY PLAN (QUICK
DEVICES)
• DEVICES – CARE & HYGIENE
• TIME MANAGEMENT
• TECHNIQUE OF LATCHING ON THE BREAST WITH SNS TUBE
• PATIENCE & PASSION