The most important reason mentioned for the early discontinuation of breast feeding and introduction of supplementary bottles is Perceived Insufficient Milk (PIM), which is relatively common in women. This is of public health concern because the use of breast milk substitutes increases the risk of morbidity and mortality among infants in developing countries and shortens birth intervals. Thus, a literary search in classical text for aetiopathogenesis, symptoms and treatment of PIM were appraised to implement in contemporary era. The classical Unani texts viz., Al Qanon fit Tib (Canon of Medicine), Al Hawi (Continens Liber), Zakheera Kharzam Shahi, Tarjuma Kamilus Sana, Tibbe Akbar, Akseer Azam, and Kitabul Kulliyat were reviewed. Further certain galactogogue herbs which are in use since antiquity such as fenugreek, cotton seeds, cumin, asparagus, black cumin etc were explored in different search engines on website for proven galactogogue activity. The causes of PIM are abnormal temperament of body or breast, anaemia, anxiety, depression, malnutrition etc. The principle treatment is treating the cause viz., the temperament is corrected by diet and drugs in abnormal temperament, elimination of humour is required in dominance of humour etc. The aforementioned drugs are proven scientifically for their galactogogue activity. The classical texts are having valuable information regarding PIM, which can be implemented in present era. Aforementioned Unani drugs are proven scientifically for with their galactogogue effect, however, clinical trials are scarce. Therefore, further randomized controlled clinical trials are recommended.
Scientific evidence overpoweringly indicates that breast feeding confers significant health benefits to mother and child and is the ideal method for feeding and nurturing infants (Mennella and Pepino, 2010) but lactation insufficiency or failure is relatively common among women (Valdez et al., 2007). Oligogalactia or Perceived Insufficient Milk (PIM) is stated as one of the reasons mentioned most often by women throughout the world for the early discontinuation of breast feeding and/or for the introduction of supplementary bottles. They also stated that the incidence of oligogalactia has been estimated to range from 23 to 63% during the first four months after delivery (Segãoera-Millãn et al., 1994). This is of public health concern because the use of breast milk substitutes increases the risk of morbidity and mortality among infants in developing countries and shortens birth intervals. Furthermore, in populations with sufficient economic resources, inadequate lactation may have minor consequences on the growth and health of the infant, because adequate substitute nourishment is available. However, in populations of low socioeconomic status, inadequate lactation can lead to severe health problems in the newborn, whereas a full lactation can assure the normal growth and development of the newborn even in situations of deficient availability of nutrients for the general population (Valdez et al., 2007). Moreover, inadequate breast feeding contributes significantly to the high prevalence of malnutrition (Mathur and Dhingra, 2009). Malnutrition has been responsible, directly or indirectly for 60% of 109 million deaths among children, two-thirds being associated with inappropriate feeding practices (Desai et al., 2008). Though certain medicines like metoclopramide and domperidone are being used for augmenting lactation but are infrequently suggested in view of their limited efficacy prospects and major safety concern. Thus, there has been no effective western medical treatment for the illness so far (Zhoe et al., 2009).
However, from earliest times of mankind a multitude of plant galactagogues has been used in the folk medicine of all human cultures. In Unani system of medicine, details regarding PIM have been mentioned. Therefore, the aim of this literary search was to explore the classical text for aetiopathogenesis, symptoms and treatment of PIM were appraised to implement in contemporary era.
The detail of lactation and PIM has been discussed in classical Unani text. The present article provides a literary search of aetiopathogenesis, symptoms and treatment of PIM from Unani classical treatises such as Avicenna’s Canon of Medicine by Ibn Sina, Al Hawi fit Tib (Continen Libers) by Zakariya Razi, Zakeera Kharzam Shahi by Ismail Jurjani, Kamilus Sana by Al Majoosi, Haziq by Ajmal Khan etc. Furthermore, to update current approaches to treat, we conducted a search of the English-language literature on various websites such as pubmed, Medline google scholar for the terms, oligogalactia, perceived insufficient milk, mother’s milk insufficiency, inadequate lactation, lactation failure and galactogogue herbs.
It is well known fact that breastfeeding is recommend as human milk is species specific sustenance for the baby, produces optimal growth and development, and provides substantial protection from illness. Lactation is beneficial to mother’s health and biologically supports a special mother/baby relationship. It is nature’s gift to baby and meant for human infant (Dawn, 2004).
We are also well aware that babies who are not breastfed, or who are fed other foods too early may have an increased risk of bacterial meningitis, respiratory and ear infections, GI problems, necrotizing enterocolitis diarrhoea, botulism, obesity, urinary tract infection, and allergic skin disorders (Desai et al., 2008). Breastfeeding is inherent and most mothers adapt to it naturally. However, at the slightest problem encountered, mothers switch readily over to top/supplementary feeding. Mother often feels that they have insufficient milk, and faces numerous physical, emotional and logistical obstacles to breastfeeding and even small anxieties about milk supply can lead to lactation failure. Failing to receive the crucial breastfeeding support will also leads to lactation failure. PIM is one of the reasons mentioned most often by women throughout the world for the early discontinuation of breast feeding and/or for the introduction of supplementary bottles (Segãoera-Millãn et al., 1994).
Unani scholars mentioned that maternal milk production is scanty in PIM. Ajmal Khan mentioned that PIM causes psychological and emotional trauma to the mother as the baby is not satisfied by the feeds, cries frequently, malnourished, and fall sick recurrently (Khan, 1983). Avicenna (Ibn Sina) in his treatise “Canon of Medicine” writes the causes of PIM should be evaluated as the milk production is scanty (Sina, 2010). He mentioned the causes of PIM are altered quality of blood where the blood element (
The literary research showed that almost all Unani scholars in their respective treatises or compilations mentioned that the one of the causes of PIM is simple or compound distemperament of the whole body or breast or dominance of humours. In conventional medicine maternal factors mentioned for PIM is insufficient breast tissue, breast surgery (reduction), poor motivation, inappropriate management of local problems in the breast e.g. flat and sore nipples, engorgement (Narayanan 1985) retracted, short or too large nipples etc (Gupte,2004) .
It was also noted that Azam Khan (1983) said that anxiety, depression, excessive intercourse can also lead to PIM. Narayanan (1985) mentioned that sedation (also influences the baby), over anxiety, excessive fatigue, drugs
It has been proven in conventional medicine that primary inability to lactate by the mother is severe illnesses such as postpartum hemorrhage with Sheehan’s syndrome, infection, or hypertension (Neifert, 2001). This opinion is in agreement with the causes mentioned by Zakariya Razi (2001), Ibn Sina (2010), and Akbar Arzani (2002) that anemia because of excessive hemorrhage, postpartum hemorrhage, etc, chronic illnesses and altered quality of blood can lead to PIM. Women suffering a PPH may experience a transient hypotensive insult and pituitary ischaemia and/or infarction resulting in inhibition of the hormonal triggering of lactogenesis Stage II by prolactin. In rare cases, women who bleed severely during childbirth may develop Sheehan’s syndrome, or ischaemic necrosis of the pituitary gland, in particular of the anterior lobe, secondary to hypoperfusion. Failure to lactate or difficulties with lactation, due to absent or deficient prolactin secretion, are common initial symptoms of Sheehan’s syndrome. In addition, elevated cortisol levels following such a stressful labour and delivery may also adversely affect lactogenesis Stage II. Delayed early contact between mother and baby following a complicated birth with PPH may also impact on a mother's ability to successfully establish and maintain breast feeding (Thompson et al., 2010) Clinicians also need to consider the possibility of retained placental fragments that can be responsible for maintaining maternal progesterone levels sufficient to delay or inhibit secretory activation (lactogenesis II) (Kent et al., 2012). Moreover, it is an established fact that poor nutrition of the mother can lead to poor growth and development of the foetus, and to an insufficient quantity of milk (Parr, 1983).
Azam Khan mentioned that patients will have symptoms depending on the cause. The other symptoms of PIM are related to the baby for example baby is not satisfied by the feeds, cries frequently, and malnourished (Khan, 1983). Ibn Sina mentioned that if the cause is abnormally hot temperament, it would be identified from the signs and symptoms. When milk is scanty due to excessive heat in the breast, it would be recognized from their feel. In abnormal cold temperament, obstruction will be present or weakness in attractive faculty (
The researchers mentioned that when milk is not sufficient, the infant does not feel satisfied after feedings, cries a lot, wants to nurse frequently, takes very long feedings and does not gain weight properly (< 20 g a day) (Bernstein and Shelvo, 1996). The number of wet diapers a day (less than problems during lactation six to eight) and infrequent bowel movements, with a small amount of stools, which are dry and hard, indirectly indicate low intake of milk. The following signs indicate that an infant is not receiving enough milk in the first weeks of life: weight loss greater than 10% of the birth weight, not regaining birth weight up to two weeks of life, no urinary output for 24 hours, absence of yellow stools in the first week and clinical signs of dehydration are other symptoms of PIM (Bernstein and Shelvo, 1996).
The dominance of humour (
The diagnosis includes history taking, clinical examination and investigations. As mentioned by the Kabiruddin (2003) and Khan (2011) that malnutrition, anaemia, excessive blood loss because of postpartum hemorrhage, psychological and emotional stress affects the general health of mother that leads to PIM. In conventional medicine in interrogation of PIM number of questions are asked about mother’s general health such as any medical conditions, complications during intra partum and postpartum period, any breast surgery, smoking, hypothyroidism, PCOS, breast changes in the pregnancy or after the birth. Anaemic women are less likely to continue breast feeding than other women (Amir, 2006).
Avicenna described that following is the mode in which feeding of infant is to be arranged. Whenever possible, the mother’s milk should be given by suckling (Grunner, 1930). As the mother’s milk is nearest to the blood from which the baby has grown up as the feotus. Such milk is better adapted for its further growth and development. The blood in mother’s breast is converted into milk. This is beneficial for the infant and more attractive and acceptable to its constitution (Shah, 2007). The treatment is advised according to the cause. In simple abnormal temperament (
Azam Khan mentioned that balance and nutritious diet is enough to treat PIM and drugs are not needed (Khan, 2011). The diet which is hot and moist such as milk, rice, chicken or honey with milk,
Bed rest, avoid strenuous exercise and work. Avoid psychological stress (Jurjani, 2010).
To increase milk production, Giugliani (2004) advice to improve latch on, if necessary, increase the frequency of feeding, eat a balanced diet, drink enough fluids and take a rest
If there are signs of cold temperament, obstruction or inadequate absorption, diet should be light (
Galactagogues (or lactogogues) are medications or other substances believed to assist initiation, maintenance or augmentation of maternal milk production. Common indications for galactagogues are adoptive nursing (induction of lactation in a woman who was not pregnant with the current child), relactation (reestablishing milk supply after weaning), and increasing a faltering milk supply because of maternal or infant illness or separation (Montgomery and Wight, 2004).
The use of natural products believed to be able of increasing milk production has a long history. Galactagogues herbs mentioned in the Unani pharmacopeia are
The seeds of
The milk yield in rats, cows, buffaloes (Kaikini et al., 1977; Kumar et al., 2008; Patel and Kanitkar, 1969; Sabnis et al., 1968) and goats (Vihan and Panwar, 1988) was increased by oral administration of roots of
The researchers in their double-blind randomized clinical trial evaluated Asparagus
The presence of steroidal saponins and sapogenins constituents has been shown to directly contribute in the lactogenic effect of
The studies conducted in buffaloes, showed that cotton seed feeding enhances the milk production significantly (
In single-blind, placebo-controlled, randomized clinical trial, kernel of
Fenugreek is a natural product that is a member of the pea family. It has been used for a variety of indications, including treatment of cough, bronchitis, sore throats, and menstrual pain. Fenugreek is used in India and in some Middle Eastern countries as a spice and a medicine. It is believed to have a number of therapeutic uses, including anti-inflammatory, reconstituent and galactagogic effect (Zuppa et al., 2010). Anecdotal reports of the successful use of fenugreek as a galactagogue have been documented as far back as 1945. However, formal published clinical data are lacking. A specific mechanism of action is unknown; however, it has been theorized that fenugreek may affect breast milk production by stimulating sweat production, and the breast is a modified sweat gland. In a clinical practice setting, Huggins describes the anecdotal use of the herb in at least 1200 women. Generally, all the women who consumed fenugreek reported an increase in milk production within 24 to 72 hours after initiation of therapy. Discontinuation of the herb can occur after milk production is stimulated to an appropriate level and maintained as long as breast stimulation and emptying continue. The recommended dose of fenugreek for use as a galactagogue is 2 to 3 capsules 3 times daily (Gabay, 2002).
In one of the study, the investigators asked 10 mothers to maintain a diary of the quantity of milk produced with a pump for a period of two weeks. In the first week, baseline milk production was evaluated; in the second week, mothers took fenugreek, 3 cups, three times daily. In the first week average quantities were 207 ml/day, whereas, milk production in the second week averaged 464 ml/day (
Human milk is species specific nourishment for the baby, produces optimum growth and development, and provides substantial protection from illness. Babies who are not breastfed, or who are fed other foods too early may have an increased risk of obesity, diarrhoea, GI problems, respiratory and ear infections, urinary tract infection, bacterial meningitis, botulism, necrotizing enterocolitis and allergic skin disorders. Hence, Mother’s milk is very important for neonates. PIM is defined as the need to start top feeds for the baby within 3 months of delivery because of inadequate breast milk supply. PIM is also known as perceived insufficient milk. Unani classical texts are enormously enriched with the knowledge of lactation, lactation inadequacy and its treatment with galactagogue herbs such as fenugreek, cumin, cotton seed,