BREASTFEEDING MEDICINE Volume 9, Number 6, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2014.0002
Moringa oleifera as a Galactagogue Peter Francis N. Raguindin,1 Leonila F. Dans,2 and Jacelie F. King1
Dear Editor:
M
oringa is an herbal galactagogue that has been widely used in the Philippines and some parts of the world. Recent systematic reviews on herbal galactagogues have appraised the use of several herbs but failed to include Moringa.1,2 Dr. E. Quisumbing was the first scientist in the Philippines to do a study on its lactogenic properties in 1987.3 In 1996, Yabes-Almirante and Lim3,4 further determined a causal relationship of Moringa capsule intake with increased milk production by demonstrating increased serum prolactin levels. We conducted an update on a previously published systematic review on the use of Moringa compared with placebo in increasing breastmilk production, infant’s weight gain, serum prolactin levels, success of exclusive breastmilk production, and adverse effects.5 Thirty-three titles and abstracts were retrieved from electronic databases (Medline, HERDIN, Scopus, and Google Scholar), hand searching, and reference tracking. The literature search was limited to human clinical trials using the search terms ‘‘Moringa oleifera,’’ ‘‘Moringa pterygosperma,’’ ‘‘Moringa,’’ ‘‘drumstick tree,’’ ‘‘horseradish tree,’’ and ‘‘Ben oil tree.’’ Six randomized, placebo-controlled, blinded, clinical trials were included in the analyses, five of which were published in the Philippines. All studies were done among Filipinos. Two were done in a community, and four were done in tertiary hospitals. Pooling of studies revealed a significant mean increase in milk volume on Day 7 (Fig. 1) among mothers who received Moringa by 124 mL (95% confidence interval, 90–159 mL; heterogeneity I2 = 0%; p = 0.32). Milk volume on Days 4 and 5 also favored the Moringa group as well, but the comparison showed significant heterogeneity, probably because of dif-
ferences in postnatal age of infant, timing of breastmilk collection, and maternal age difference.6,7 Of particular interest is the difference in study designs between preterm and term infants. Milk collection for preterm infants involved breastmilk expression either by hand or by machine, and the infants were fed through gavage. For term infants, on the other hand, milk expression and measurement of outcome were done after breastfeeding. This resulted to measurement of residual volume after initial emptying by the baby. The reported milk volume for term infants may therefore be an underestimate. Pooled analysis of the two studies with a total of 73 patients showed a significant increase in the weight of infants during week 4 with a mean difference of 11.9% (95% confidence interval, 5.5–18.2%; heterogeneity I2 = 0%; p = 0.61), which favors the experimental group. The lactogenic effect of Moringa is hypothesized to be the induction of prolactin production in the anterior pituitary gland. The two studies (Fig. 2) that reported on prolactin levels showed that patients in the Moringa group had higher levels with a statistically significant mean increase of 19.5 · 102 mIU/L (95% confidence interval, 16.8–22.2 · 102 mIU/L; heterogeneity I2 = 44%; p = 0.18). Timing of outcome measurement is indeed an important variable because growth of infants is dependent on their postnatal age, and prolactin serum levels have varying levels across postpartum days.8 Safety profile was merely obtained through self-report, of which no adverse event was seen among the six studies. There were no studies that investigated exclusive breastfeeding as an outcome. Overall, these six randomized controlled trials suggest that Moringa can result in a significant increase in breastmilk volume on Day 7. It also results in improvement in the infants’ weight gain. This herbal galactagogue also shows a
FIG. 1. Forest plot of breastmilk volume (measured in mL) collected on Day 7.9,10 CI, confidence interval; IV, inverse variance, random effects model; SD, standard deviation. 1 2
Department of Pediatrics, Philippine General Hospital, University of the Philippines, Manila, Philippines. Department of Clinical Epidemiology, College of Medicine, University of the Philippines, Manila, Philippines.
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LETTER TO THE EDITOR
FIG. 2. Forest plot of maternal serum prolactin levels (in ·102 mIU/L) taken at 4 months.3,4 CI, confidence interval; IV, inverse variance, random effects model; PCMC, Philippine Children’s Medical Center; SD, standard deviation. possible effect in increasing prolactin levels, but pharmacodynamics of the drug have to be investigated further to establish causality. Future research studies can venture into bigger and well-designed trials with subset analyses on several maternal and neonatal factors. Investigations can also be done on a different population or by looking into success of exclusive breastfeeding and improvement of neonatal outcomes. References
1. Budzynska K, Gardner ZE, Dugoua J-J, et al. Systematic review of breastfeeding and herbs. Breastfeed Med 2012;7: 489–503. 2. Mortel M, Mehta SD. Systematic review of the efficacy of herbal galactogogues. J Hum Lact 2013;29:154–162. 3. Yabes-Almirante C, Lim M. Effectiveness of natalac as a galactagogue. J Phil Med Assoc 1996;71:265–272. 4. Yabes-Almirante C, Lim M. Enhancement of breastfeeding among hypertensive mothers. In: Yabes-Almirante C, De Luna M, eds. Increasingly Safe and Successful Pregnancies. Elsevier Science, New York, 1996:279–286. 5. King J, Raguindin P, Dans L. Moringa oleifera as galactagogue for breastfeeding mothers: A systematic review and meta-analysis of randomized controlled trial. Phil J Pediatr 2013;61:34–42. 6. Neville MC, Keller R, Seacat J, et al. Studies in human lactation: Milk volumes in lactating women during the
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onset of lactation and full lactation. Am J Clin Nutr 1988; 48:1375–1386. Dewey KG, Finley DA, Strode MA, et al. Relationship of maternal age to breast milk volume and composition. In: Hamosh M, Goldman A, eds. Human Lactation 2. Springer, New York, 1986:263–273. Ingram JC, Woolridge MW, Greenwood RJ, et al. Maternal predictors of early breast milk output. Acta Paediatr 1999; 88:493–499. Espinosa-Kuo C. A randomized controlled trial on the use of Malunggay (Moringa oleifera) for augmentation of the volume of breastmilk among mothers of term infants. Fil Fam Phys 2005;43:26–33. Co M, Hernandez E, Co B. A comparative study on the efficacy of the different galactagogues among mothers with lactational insufficiency. Phil J Pediatr 2002;51:88–93.
Address correspondence to: Peter Francis N. Raguindin, MD Department of Pediatrics Philippine General Hospital University of the Philippines Taft Avenue Ermita, Manila 1000, Philippines E-mail:
[email protected]
