Breastfeeding and milk supply

The evidence on galactagogues is weak, and the most common cause of perceived low supply is not a pharmacological problem.

Most low-supply concerns are position and latch. If the baby is not transferring milk effectively, supply falls because supply is driven by demand. A lactation consultant can assess this in person, and it is the intervention with the best evidence. This is the right first step and it is under-used.

Fenugreek is the most-used galactagogue and the trial literature is low quality: where a pooled analysis found an effect it was small and the confidence was low. It is generally well tolerated; side effects include GI upset, and it can lower blood glucose. It can also cause a maple-syrup smell in the mother and the baby.

Milk thistle (silymarin) has a small randomised trial showing an increase in milk production. The evidence is thin.

Domperidone is a prescription dopamine antagonist used as a galactagogue in some countries. It is not without cardiac risk and it is a clinical decision.

What actually helps supply. Frequent and effective milk removal — feeding on demand, and if supplementing, expressing to keep the demand signal. Skin-to-skin contact. Treating pain or a poor latch. Adequate hydration and nutrition. Sleep, which is difficult and matters. And reassurance, because perceived low supply with an adequately growing baby is common and the baby's weight curve is the objective test.

What reduces supply. Anything that suppresses prolactin or is a dopamine agonist — and that includes large doses of some common herbs — plus smoking, alcohol, some medications, and dehydration. Pseudoephedrine reduces supply, which surprises people taking a decongestant.

Mastitis — a red, hot, painful breast with fever and flu-like aching — needs prompt attention and often antibiotics; it can progress to an abscess. Keep feeding or expressing from the affected side, because emptying helps, and see a clinician promptly. A fluctuant lump with high fever suggests an abscess, which needs drainage.