BREASTFEEDING MEDICINE

Volume 9, Number 9, 2014 Invited Review

ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2014.0133

Treatment of Maternal Hypergalactia

Anne Eglash

Introduction suckling or other forms of nipple stimulation such as

pumping. Oxytocin release from the posterior pituitary gland

M any breastfeeding mothers struggle with an over-

abundant milk supply, or hypergalactia, beyond the
first few weeks of engorgement. There has been very little
occurs in response to several types of sensory input, such as
seeing, hearing, smelling, or touching the baby. Myoepithe-
lial cells, which surround alveoli and lactiferous ducts, re-
research done to define, to explain, or to assist in managing spond to oxytocin stimulation by contracting to induce milk
this problem. Lactation specialists have identified several ejection. Oxytocin release is inhibited by pain and stress.10,11
challenges for women with hypergalactia.1 A mother’s milk supply is also under local control intrin-
Hypergalactia is also termed hyperlactation, oversupply, sically within the breast. Fullness of the breast, within alveoli,
and engorgement, depending on the literature. The 10th In- is an important factor in controlling milk production. A very
ternational Classification of Diseases uses the terms hy- full breast is expected to slow milk production, not by simple
pergalactia, hyperlactation, and increased lactation. The term distension,12 but by an increase in the concentration of the
that is most consistently found in dictionaries to describe ‘‘feedback inhibitor of lactation,’’ now known to be nonneural/
excessive milk is hypergalactia. peripheral serotonin (5-hydroxytryptamine [5-HT]).12,13
Because there is not an operational definition with criteria There is a paucity of information in the literature de-
for hypergalactia, the diagnosis would be based on the cli- scribing the percentage of nursing mothers with hyperga-
nician’s impression. A commonsense definition would be the lactia, whereby these mechanisms of milk production don’t
state of producing excessive milk, which leads to discomfort achieve a healthy balance of milk production. In addition,
and may compel a nursing mother to express and store milk there are no human studies to date that have evaluated the
beyond what the baby is taking, assuming normal infant underlying etiology for hypergalactia. Many clinicians use
growth. The caveat of normal infant growth is important behavioral strategies and antilactational substances to help
because mothers may feel too full at times when the baby is reduce the milk supply.
not transferring sufficient milk. An excessive milk supply Maternal symptoms of hypergalactia include breast full-
may appear to be cause for celebration by mothers with in- ness, an inability to nurse the baby from both breasts for each
sufficient lactation, but mothers with hypergalactia are at feeding, and a heavy let-down reflex. The heavy let-down
increased risk for a fast let-down,2 acute mastitis,3 plugged reflex may lead to a shallow latch by the infant, resulting in
ducts,4 chronic breast pain,5 exclusive pumping,6 infant sore nipples. The mother may also struggle with excessive
fussiness,7 and early weaning.8 milk leakage, chronically tender engorged breasts, plugged
Many women self-induce hypergalactia by various means. ducts, and mastitis due to irregular and insufficient breast
Pumping in addition to nursing stimulates extra milk pro- emptying. Infant symptoms include choking and gasping
duction. Many herbal supplements are used to increase the during the initial let-down, excessive weight gain, fussiness
milk supply, such as alfalfa, fenugreek, goats rue, fennel, at the breast, excessive flatus, and explosive, green stools.
blessed thistle, saw palmetto, and shatavari.9 New mothers Hypergalactia may be associated with a foremilk–hindmilk
are often instructed to nurse their babies according to the imbalance, leading the baby to consume a high proportion of
clock, such as 15–20 minutes on each breast, rather than foremilk. High foremilk intake has been suspected in some
nursing according to infant feeding cues. This leads some cases to be associated with blood-streaked infant stools that
mothers to nurse for longer periods of time than the baby contain mucus.7
needs to, raising the prolactin level further.7 Evaluation of hypergalactia could include thyroid function
This article is referring to women who persist with hy- tests to rule out either hyper- or hypothyroidism. In addition,
pergalactia despite optimal behavioral interventions to reduce a prolactin level could be measured to see if it is quite ele-
the milk supply. vated. All successfully lactating women should have an ele-
A mother’s milk supply is under extrinsic endocrine con- vated prolactin level, so it would be difficult to determine if
trol from prolactin and oxytocin. Prolactin is secreted from hypergalactia is truly due to a primary hyperprolactinemia.14
the anterior pituitary gland in response to nipple stimulation The most common behavioral strategy reported to help
and stimulates milk secretion from lactocytes. The prolactin hypergalactia is block feeding.1,7 This involves the mother
level is regulated by the frequency and duration of infant nursing from one breast for 3-hour blocks ( – 30–60 minutes).

Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Mt. Horeb, Wisconsin.

423
424 EGLASH

Table 1. Substances That Reduce the Milk Supply Peppermint oil might reduce the milk supply when used
topically. Peppermint in high doses can be toxic and should
Class Compound be kept away from the baby.19
Herbs Sage leaves Homeopathy
Peppermint
Chasteberry Homeopathic medications are based on the ‘‘Law of Simi-
Parsley lars,’’ or ‘‘like curing like.’’ The principle is that substances
Jasmine given in low doses may be effective for symptoms that are
Pharmaceuticals Pseudoephedrine produced when the substance is ingested in high doses.20 Po-
Estrogen
Carbergoline tency of homeopathic medications are determined by the di-
Bromocriptine lution of the substance. For example, a 30C dilution indicates
that the substance has been diluted to 10–60. Homeopathic
medications found to be helpful in reducing the milk supply
include lac caninum 30C, Pulsatilla 30C, and Ricinus com-
For example, the mother nurses from the right breast from munis 30C. These are purchased as small pellets. The typical
noon to 3 o’clock. Then from 3 to 6 o’clock all nursing comes dose is five pellets sublingually two to three times a day, until a
from the left breast. This allows one breast to remain undis- decrease in milk supply is noticed. The medication is then used
turbed for 3 hours or more at one time, so that local control two to three times a day as needed to keep the milk supply
from an increase in 5-HT will provide feedback to lactocytes down. There are minimal to no side effects noted with ho-
to decrease the milk supply. Usually within 24–48 hours the meopathic agents, other than gastrointestinal intolerance to the
mother notices a significant decline in her milk supply. Oc- lactose that is added to the pellets.
casionally the supply will drop so much that mom will need to
nurse from both sides for each feeding. Pharmaceuticals
If block feeding is not successful, the next step would be to
try various supplements or medications to reduce the milk Pseudoephedrine is a commonly used decongestant that has
supply (Table 1). Common substances include herbs, home- been found to decrease the milk supply. One study found that a
opathy, pseudoephedrine, estrogen in the form of the com- 60-mg dose of pseudoephedrine was associated with a 24%
bined birth control pill, and, finally, antiprolactin medications. decrease in milk production. It is unclear if the effect is
Sometimes these substances are needed to help a woman achieved by decreasing the prolactin level.21 Pseudoephedrine
wean because the normal mechanism of breast fullness re- could first be given as a 30-mg dose, watching for side effects
sults in complications such as plugged ducts and mastitis, of jitteriness, irritability, and insomnia. If the 30-mg dose does
making it difficult to fully wean. not decrease the supply in 8–12 hours and it is tolerated well,
the mother could increase the dose to 60 mg. Once the mother
notices a drop in her milk supply, she can use it every 12 hours
Herbs
as needed to keep her supply down to a manageable level. It is
A few herbs are clinically useful to reduce the milk supply. important to not prescribe this for a set duration of time, such
Sage, or Salvia officinalis, is the most common herb used to as twice a day for 3 days, as this may drop the supply too low.
reduce milk supply. Sage tea or extract made from the leaves By using it just as needed, the mother can more carefully
is typically recommended, although there are no studies on determine her body’s response to the medication.
the use of sage for hypergalactia and very few on its effect on Estrogen has a negative effect on lactation, reducing the
the nursing baby.15 Sage tea may be prepared by steeping 1– milk supply.10,22,23 Estrogen can be given as the combined
3 g of dried sage leaves in a cup of hot water.16 There are birth control pill, once a day for a week, and then stopped.
several commercial preparations of sage extract available. The mother should see a decline in her milk supply by 5–7
The mother should be advised to just use one dose of the days. If her supply rises over time, she can be treated again
extract (as recommended by the manufacturer) or 1 cup of tea short term with the combined birth control pill.
and to observe the effect on her supply, as well as any be- Treatment with estrogen increases the risk of thrombo-
havioral change in the baby, over the next several hours. embolism in the mother, especially if prescribed before 4
If she does not notice a difference in supply in 8–12 hours, weeks postpartum.23
then she can try another, stronger dose. Once she sees a re- If none of the preceding treatments reduces the milk sup-
sponse, she should just use it as needed. Often women will use ply, the final step would be to use an antiprolactin medication
one dose every 12 hours for 3 days to keep their supply down. such as bromocriptine or cabergoline. Both are effective in
Sage is known to have several side effects in high doses, reducing the milk supply early postpartum. Cabergoline has
including nausea, vomiting, and dizziness. It can induce been shown to have fewer side effects than bromocriptine.24
wheezing, lower the blood sugar, and induce seizures, so high However, very little is known about transmission of ca-
doses should be avoided in asthmatics, diabetics, and people bergoline into breastmilk, whereas very little bromocriptine
prone to seizures. It is considered safe when used as a food.15,16 is transferred into breastmilk.25
Jasmine flowers applied topically and chasteberry taken There are no published reports on the effectiveness of ei-
orally are both suspected to reduce the prolactin level and ther of these medications in the treatment of hypergalactia
may have an effect on reducing milk production. Very little during later stages of lactation.
research exists to guide clinical use of these herbs.17 Because of cabergoline’s lower side effect profile, I have
Parsley is believed to reduce the prolactin level and could chosen to use cabergoline 0.25 twice a day for 1 day as the
reduce the milk supply when eaten as a food, such as in tabouli.18 last resort in nursing mothers with hypergalactia who have
TREATMENT OF MATERNAL HYPERGALACTIA 425

not responded to other treatments, particularly for mothers tight junctions. Proc Natl Acad Sci U S A 2007;104:16708–
who are attempting to wean without success. Cabergoline is 16713.
long acting, with a half-life of 63–69 hours.26 For that reason, 13. Hernandez LL, Stiening CM, Wheelock JB, et al. Evalua-
I advise mothers to express and discard their breastmilk for tion of serotonin as a feedback inhibitor of lactation in the
approximately 5 days after using cabergoline. bovine. J Dairy Sci 2008;91:1834–1844.
14. Adamopoulos DA, Kapolla N. Prolactin concentration in
milk and plasma of puerperal women and patients with
Conclusions galactorrhea. J Endocrinol Invest 1984;7:273–276.
Women with true hypergalactia are at risk for medical 15. LactMed Database. Sage. Available at http://toxnet.nlm
complications of breastfeeding, including maternal pain and .nih.gov/cgi-bin/sis/search2/f?./temp/*V9u6ic:1- (accessed
infections, as well as infant symptoms of gastrointestinal September 5, 2014).
distress. These mothers often have difficulty weaning. There 16. Sage. Available at www.consumerlab.com/tnp.asp?chunkiid =
are several strategies that can be used to help lower the milk 111802- (accessed September 6, 2014).
supply, including changes to the feeding strategy, comple- 17. Budzynska K, Gardner ZE, Dugoua JJ, et al. Systematic
mentary medications, and pharmaceuticals. Mothers should review of breastfeeding and herbs. Breastfeed Med 2012;
7:489–503.
be followed over time to properly management side effects
18. Schaefer C. Drugs During Pregnancy and Lactation, 2nd
and outcomes of treatment. ed. Elsevier BV, Amsterdam, 2007, pp. 4, 13.
19. Conover E, Buehler BA. Use of herbal agents by breast-
Disclosure Statement feeding women may affect infants. Pediatr Ann 2004;
33:235–240.
No competing financial interests exist.
20. Pizzorno JE, Murray MT. Textbook of Natural Medicine,
4th ed. Churchill Livingstone, Elsevier, London, 2013, pp.
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homeostasis employs serotonergic regulation of epithelial E-mail: areglash@wisc.edu