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Sage Advice on Herbs and Breastfeeding

Leaders Need to Approach Herbs with the Same Caution Used to Answer Mothers' Questions about Medications

Sheila Humphrey
From: LEAVEN, Vol. 34 No. 3, June-July 1998, pp. 43-47

Ed. Note: We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time.

There has been an enormous resurgence in the study and use of herbs and herbal preparations in all parts of the world (Akerele 1993). Herbs, or plants used for medicinal or health purposes, are more widely available now than they were just a few years ago. In many countries, herbs and herbal preparations are readily available not only in pharmacies but in many grocery stores. Many books and articles have been written suggesting uses of herbs for health-related conditions. Television and newspapers report on herbal "discoveries" and scare stories, in addition to advertising herbal products.

More and more often, Leaders are called by breastfeeding mothers looking for information about herbs. A mother may ask if a specific herb or combination herbal product is safe for her breastfeeding baby. She may ask if taking a particular herb will increase her milk supply.

What does a Leader tell a mother about herbs? Should she check with a Professional Liaison (PL) Leader? How can a PL Leader help?

This article helps clarify the issue of herbal safety as it applies to breastfeeding and takes a peek at the kind of information available on herbs and lactation. It is intended to help Leaders answer mothers' questions about herbs with reliable referenced information, just as we do with medication. In this article, both prescription and over the counter (OTC) drugs are referred to as medications. Herbal medicines, medicinal plants and herbs are used interchangeably.

Kinds of Herbal Information

Scientific information about herbs tends to come from two related disciplines: ethnobotany and pharmacognosy. Ethnobotany is the study of the traditional and cultural use of plants. Ethnobotanists study prehistoric, historic and present-day herbal practices. Pharmacognosy is the scientific study of naturally derived substances and their effects on the body. Here, medicinal plants are of principal interest. Modern Western pharmacology originated with the scientific investigations of European herbalism. A significant proportion of medications used today are still derived from plants (Akerele 1993).

Traditional or folkloric knowledge of medicinal plants is an integral part of a culture's understanding of health and disease. Every culture on earth has herbalist lore, a storehouse of knowledge handed down over the generations. For most people on the earth, herbal medicines are the only medicines available. Many ethnic traditions have been integrated into current herb use in Europe and North America. European Herbalism, Traditional Chinese Medicine, North American Indian Traditional Medicine and Ayurvedic Medicine of India all continue to be explored as new sources of botanical healing.

Pharmacological investigation of herbs is a rapidly maturing field, though much yet remains to be done. Not all of the traditional uses of herbs have held up under scientific scrutiny. Indeed, some have turned out to be at best ineffective, on occasion even toxic. Traditional use is considered anecdotal, information that comes from individual cases, not from statistical studies of groups applying the scientific method. An herb's traditional reputation is often the accumulation of many individuals' experiences with the herb. Somewhat analogous to "many mothers' experiences" with breastfeeding, traditional information is useful and, often enough, may be the only information available.

Herbs are often used in combinations that are believed to take advantage of additive and/or synergistic effects of each herb in the recipe or remedy. While noting that traditional herbalist practices from around the world reflect this understanding of herbs, it is beyond the scope of this article to explore these fascinating aspects of herbal medicine.

Scientific investigation of traditionally used herbs has led to many pharmacological discoveries throughout history. Experts in pharmacognosy are interdisciplinary, being knowledgeable about the botany, chemistry and pharmacology of medicinal plants. Pharmacognosists also study the traditional uses of plants as this is an important guide to further scientific investigations. Although the general body of scientific knowledge about plant medicines is growing rapidly, very little attention has yet to be focused on the use of herbal medicine during lactation.

Good scientific herbal texts and monographs (formal summaries of knowledge) offer referenced information on what is known about a plant's use as a medicine (Bisset 1994). You can expect to find the full botanical name of the plant, its chemistry, the pharmacologically significant constituents and how they behave in the body. Traditional indications of use are described; when available, scientific evidence for those uses is presented. General forms of the medicinal herb, its dosage and routes for use are usually found. Information on the safety of an herb is given and any cautions associated with its use are an important part of the description. Toxicity effects and side- effects are described. Possible cautions about adverse interactions with other medications or herbs are included.

Note that these texts generally address single herbs, not multiple herb preparations. Scientific information on the pharmacological actions of combination herbal preparations is relatively limited at present.

Scientific herbal texts, such as Bisset, Newall et al, Leung and Foster or Potter (see references for full citations), offer such information, although no one text is comprehensive. As these texts include both folkloric and scientific information, they provide the best summary of information when answering a mother's breastfeeding question. Sharing scientific information about an herb can help a mother who wishes to discuss herb use with her health care provider. When a health care provider has expressed concern about herbs, a mother is best served when a Leader can give her scientific information, as is also the case with medications.

Safety of Herbal Products

"Based on published reports, side-effects or toxic reactions associated with herbal medicines in any form are rare" (Farnsworth 1993). However, to fully respect a mother and her breastfeeding relationship with her baby, a cautious attitude toward all herbs used during lactation is appropriate. Knowing the safety issues with herbs can help ensure that appropriate information will be given about them.

Most of the adverse effects reported for herbal medicines are associated with "crude drugs" or powdered forms of plant material (Farnsworth 1993). In North America, herbs are sold mostly in crude (whole plant) form, typically for use in tea or gelatin capsules. When making tea, the strength of the infusion can vary depending on the quality of the herb, the amount of herb and water used as well as brewing time. For a cup of chamomile tea, this hardly matters, but for more potent herbs, knowing how much the mother is taking may be a safety issue. For example, the use of laxative herbs (e.g.. cascara) as a tea will pose a higher risk compared to standardized preparations where the dose is controlled.

In Europe, many herbs are commonly available as concentrated extracts in the form of alcohol extracts, tablets, syrups, etc. The strength or concentration of herbal extracts is consistent from hatch to batch, that is, made with a measured concentration of plant material. The consumer can read the concentration and recommended dose on the label. A few herbs are further standardized to a specific constituent of the plant. It is not always conclusively known if this constituent is responsible for the herb's effects. Its presence on the label generally indicates that the herbal product is of good quality as the manufacturers of these products are generally advanced in the area of quality control (Farnsworth 1993). Standardized herbal products are becoming more widely available in North America.

Good quality control programs ensure that an herbal product contains correctly identified, properly handled plant material with no bacterial, fungal or other contaminants or adulterants present. There have been cases of toxicity in herbal preparations due to misidentification of plants or even deliberate adulteration with nonmedicinal plant material. Occasional cases of toxic reactions have been traced back to adulteration of the herbal preparations with heavy metals or even prescription drugs (Farnsworth 1993).

Gather information on the herb a mother is asking about carefully. What is the name of the herb or herbal preparation, including the botanical (Latin) and common name of the plant(s)? In combination products, all the plant names are important. Dose- related information would include the weight of the capsules or tablets, the concentration and volume of liquids or tea. If the preparation is standardized, information on the percentage and names of these constituents will be on the label of the product. The recommended product dose is also helpful. Herbal products vary widely, so questions about the actual dose taken are of primary importance.

Is an Herb Safe to Use?

Leaders cannot tell a mother that any medication is safe to use during breastfeeding. Using her knowledge of breastfeeding, the Leader can help the mother understand how the age of her baby and the amount of breast milk consumed will affect risk, as well as suggest ways to communicate the enormous benefits of breastfeeding to her health care provider. The Leader can also share medical research about the medicine in question that she knows to be accurate, scientific and reliable. It is not within the Leader's role to suggest alternative medications, however.

As each mother's situation is unique, the Leader's response to her herb question demands the same cautious approach. Questions about the child (age, amount of nursing, health, etc.) remain pertinent. Ask why the mother is taking the herb. Will it be taken for a few days or for a long period? What has her health care provider said about using the herb, including alternative suggestions (medication or herbal) for her to consider?

As with medications, Leaders cannot tell mothers that an herbal medicine is safe but we can share information about the herb in question. Herbs differ in their potency, toxicity, potential for allergic reaction and adverse effects. For many herbs, such adverse reactions are only seen with increased close levels. Safety during lactation introduces unique issues to consider.

It is largely unknown whether herbal components penetrate human milk. As with almost all other medications, it is safe to assume that they probably do. The biochemical reactions that govern any chemical's entry into the milk undoubtedly operate with herbs as well. Most herbs do not contain large amounts of any one active substance, although the number of constituents may be very large. Applying the very general rule that about 1% of a chemical enters human milk, it is not likely that significant amounts of an herb's chemical constituents will enter breast milk. It is important to keep in mind, however, that toxic constituents of some plants have caused adverse reactions through human milk.

It is of interest here that in some traditional societies, mothers will take certain herbs to remedy problems in the baby rather than giving the herb directly to the baby (Gutmanis 1995). This indicates an awareness of the ability of herbal constituents to enter human milk. The practice also avoids the direct feeding of the herb to the baby.

Herbs contain many chemicals that the plants manufacture themselves and are a naturally occurring component of the species. For example, flowers manufacture perfumes to attract pollinators. Some of these compounds smell and taste wonderful; chocolate and coffee are favorites. Many plants contain chemicals to protect them from animals that would eat them. Some of these turn out to be harmful to humans, even in small amounts. A few plants such as jimson weed (Datura stramonium) are extremely toxic and are known poisons.

Obviously, a dangerous herb is not to be used by anyone let alone a lactating mother. Certain classes of plant compounds are now understood to be potentially dangerous to ingest in even small quantities. Herbs known to contain chemicals that produce cancers, mutations or cause liver damage (hepatotoxic) are now rightly viewed with caution (Newall 1996). For some plants, the risk posed by their cancer- or mutation- causing has been questioned. However, with certain chemicals such as those found in some comfrey species (Symphytum), evidence clearly indicates that internal use will damage the liver. Some even urge that use of comfrey on open wounds should be avoided (Tyler 1994). Herbal texts more than ten years old may not reflect this current knowledge. As ancient as some uses for herbs are, it is prudent to have up-to-date information on herbs.

Some herbs are known to contain relatively toxic components. While there may still be therapeutic applications for such herbs or herb concentrates, the unsupervised use of relatively toxic herbs in lactation could be hazardous. A mother should be urged to first consult with a health care provider knowledgeable in lactation and herbs and/or consider alternative therapies. Special circumstances in lactation also require caution. For a premature baby or newborn, even providing that the breast "filters out" most of these compounds to a large extent the potential risk of toxicity would be increased, as is the case with medications. Use of any substance applied to the breast or nipples could easily lead to ingestion by the nursing child. In this regard, the use of plant essential oils requires caution. Essential oils are a purified concentrate of a plant essence, which contains much of a plant's physiologically active constituents. The internal use of many essential oils by adults is considered unwise so care should be taken to avoid using essential oil preparations on or near the breast where baby could ingest it. Preparations that contain menthol, a significant component of peppermint oil, may require special caution. External use of menthol has been documented to have caused severe breathing difficulties in one infant (Leung and Foster 1996).

Although various herbal gels, ointments or creams are often suggested for use on the nipple, such treatments are considered difficult to remove before nursing and are of unproven effectiveness. Like many other substances known to irritate babies when applied near the breast (e.g., underarm deodorant, perfume), the smell or taste of these substances could also upset baby. Other than Lansinoh for Breastfeeding Mothers, which is a highly purified medical grade anhydrous modified lanolin, nipple remedies are not currently recommended.

Some herbs are known to have caused allergic reactions, for example, chamomile, feverfew and yarrow, which are all members of the Compositae plant family. Although cases of acute allergic reaction to these herbs are very rare, a mother needs to know that the risk of sensitization may be there. She may have a family history of allergy and be taking special care to avoid allergens. Of course a number of food plants, notably peanuts and other nuts, can also trigger allergic reactions. Observing the baby for signs of allergic reaction to a mother's herb consumption is good common sense.

It is often suggested that babies be given herbal teas, especially for the treatment of colic and often in significant volumes that could interfere with breastfeeding. It is important for herbs to be considered foods in this context-not recommended for babies under six months and introduced with caution thereafter. The practice of using herbal tea for a baby introduces a risk of sensitization where previously there was none. Use of contaminated water in preparing the remedy could also introduce risks.

When a mother is considering direct feeding of herbal remedies, the Leader's role is educational, assisting the mother to make an informed choice. She may indeed decide to feed her baby an herbal remedy but at least she will know how this use may impact her baby in regard to the benefits of breastfeeding.

When Herbs Are Food

Many herbs are also foods, thus we may think them harmless for the mother to use. Most of the time this is true, but some culinary herbs may produce problems when used extensively. Usually side-effects are seen only with increased dosage. It is prudent for a breastfeeding mother to be knowledgeable about herbs that she consumes on a regular basis, or in large amounts, in order to avoid undesirable effects. Ask a mother if she eats large amounts of any foods, including culinary herbs.

A therapeutic dose is considered an amount that tradition and/or pharmacological study indicates will have an effect on body function. A therapeutic dose is not always larger than the amount received through diet. Unexpected benefits have recently been documented for everyday items like tomatoes, grape juice, onions, etc. Many foods and culinary herbs (e.g., garlic, sage and cranberry) also have established therapeutic dose ranges for some problems (see box).

Sage (Salvia officinalis) is noted in lactation and herbal texts alike as having a folk reputation for lowering milk supply (Bissett 1994, Riordan: and Auerbach 1993). Peppermint (Mentha piperita) and parsley (Petroselinum crispum) are viewed by some traditional herbalists to lower milk supply, especially if the oil is taken internally in therapeutic doses (Ody 1994). Keep in mind that consumed on occasion, in small amounts and as part of a reasonably varied diet, peppermint, parsley, sage and other culinary herbs currently have no documented negative effect on lactation.

We are entering an age where our new understanding of foods and herbs is blurring the lines between plants and medicine. LLL believes that good nutrition means eating a well-balanced and varied diet of foods as close to their natural state as possible. Words for the wise, indeed.

Herbs and Lactation - What Is Known

Both traditional herbal texts and pharmacognosy sources make reference to pregnancy and breastfeeding as special circumstances where caution or contraindication of use are frequently indicated. Some sources treat both conditions together without exception, even though the separate states of pregnancy and lactation have different considerations. Sometimes the bias of the author has generated a blanket contraindication such as when the author does not believe any herb should be used in pregnancy and lactation (Newall et al. 1996). Traditional herbal texts are sometimes more discriminating in providing cautions specific to pregnancy or lactation (Ody 1994).

Although several hundred plants have been described in ethnobotanical literature as galactogogues (increasing the secretion of milk), only a handful of plants have been investigated (Bingel & Farnsworth 1994). It is likely that future research will show that there are a number of ways in which different plants may affect lactation. Many but not all of these galactogogue plants have been found to demonstrate estrogenic, oxytocic or other hormonal effects in lab conditions or with animals. Little is known of their effectiveness beyond anecdotal and traditional information. Keep in mind that their use by an unsuspecting mother for other purposes could conceivably cause oversupply- related difficulties.

With the few herbs reputed to decrease milk supply, no specific warning for use during lactation is clearly given in scientifically oriented sources. Instead, they may state that the herb has been used during weaning or used in treating galactorrhea or even mastitis. A statement such as "Therapeutic doses during lactation may reduce milk supply" would be more helpful. Since almost no studies have been done, it would seem the course of least risk for these sources to clearly refer the reader to traditional information when discussing such herbs.

This is a huge topic with few established facts regarding breastfeeding. Unfortunately, further exploration of these issues lies outside the scope of this article. Leaders will need to apply their breastfeeding expertise and critical reading skills when using herb information sources, keeping in mind that the authors are not necessarily knowledgeable about lactation. While a certain emphasis on toxicology issues is necessary, it is still fair to say that for many of the herbs widely available today, toxicology studies have shown them to be relatively safe. Several reviews of herb use have also shown that the occurrence of adverse reaction is relatively rare in the general population (Humphrey and McKenna 1997). Herbs have not as yet been proven conclusively to alter lactation, but there is every reason to consider that they do, as so many mothers have found.

Consider Herbs as Medicine

The PL Leader in your area may have additional information on herbs. In most cases, more than one scientific source of information can be located. As with any medicine, the mother needs to discuss the use of herbs with her health care provider. She needs to be aware of the effects and possible side-effects of the herb. Taking herbs in therapeutic doses can have unintended side-effects or may interact with other medications.

Previously unknown adverse reactions as well as unrecognized benefits of herbs have been revealed only when large numbers of people start using an herb. Reporting cases where there were unexpected or adverse reactions to an herb during lactation would help improve future herb information sources. To be truly helpful, all the details of use, particularly the identity and dose of the herb as well as the age of the child and extent of nursing should be asked of the mother and reported to the PL Leader. Until more scientific studies are available, such reliable anecdotal reports can be useful to reflect "what many mothers have found."

It is easy enough today to find that such and such an herb is recommended for this or that condition. All sorts of snippets of information regarding herbs as well as herbs and lactation can be found in books, magazines and even on the Internet. The anecdotes may be food for thought and useful as starting points to find out more about an herb's action. However, they are not the most complete sources to use when working with a mother. Think of herbs in the same manner as medications and use the same cautious approach when answering questions about them.

Ed. Note: LLL liability insurance covers Leader responsibilities only. It is beyond the scope of Leader responsibility to suggest herbs for the treatment of medical conditions, although reliable information about an herb may be shared. Leaders who are also professional herbalists will need to keep these two roles separate when working with a mother.

Herbs - Key Considerations

  • Ask about the name of the herbal preparation. Ask for the name or names of the plants or other components of the product. Include the plant's Latin name if at all possible. For combination products, ask for a list of ingredients.
  • Verify the dose. Include the weight of the capsules/tablets or if it is a tea, the details of its preparation. Include volumes of liquid preparations such as tinctures. If standardized, ask the name and amount (percent) of the constituents as listed on the label. What dose does the product label suggest?
  • Ask why the mother is taking the herb. How long will she be using the herb? What other herbs or medications does she take and why?
  • Ask the mother about her diet. What foods or herbs does she eat a lot of? Does she drink a lot of tea, coffee, herbal teas?
  • Ask about the baby - age, amount of nursing, health, etc.
  • What has the health care provider said about using the herb? Have alternatives been suggested (herbs or medication)? Is continuing breastfeeding while taking an herb or medication an issue?
  • Leaders cannot tell mothers that an herbal medicine is safe for breastfeeding but we can share reliable information about an herb. Contact a PL Leader just as you would to find the latest information available about a medication. The PL Leader may need to seek information beyond the Area level in order to answer a mother's question.
  • Consider contacting the PL Leader if a mother has experienced a beneficial or adverse breastfeeding effect with an herb. Details on its use are very helpful to include.

Examples of Therapeutic Doses of Culinary Herbs

Garlic - The German Commission E monograph on garlic states that 4 grams fresh garlic (1-2 cloves), when taken daily, may have a beneficial effect on blood lipid levels (Blumenthal et al 1997).

Sage - The German Commission E monograph on garden sage indicates a daily dose of 3 grams (2 teaspoons) dried sage infusion in 100 ml (about 3 1/2 oz.) boiling water and allowed to cool before drinking will reduce excessive secretion of sweat. The amount of sage that could adversely affect lactation is not established.

Cranberry juice - Human studies have found significant reductions in bacterial levels in urine when subjects with chronic urinary tract infection drank 300-480 ml (10-16 oz.) commercially prepared cranberry juice drink per day (Siciliano 1996).

International Herb Use

The World Health Organization (WHO) estimates that about 80% of the world's population depends on traditional herbal medicines and traditional practitioners for their primary health care. In the USA, a quarter of all prescriptions written between 1959 and 1980 contained herbal extracts or isolated active constituents of herbs. WHO has recently developed guidelines for the investigation of traditional plant remedies after recognizing the worldwide need for reliable, up-to-date information on both their benefits and risks (Akerele 1993).

References

Akerele, O. Summary of World Health Organization guidelines for the assessment of herbal medicines. HerbalGram 1993; 28,13-20.

Bisset, N. Herbal Drugs and Phytopharmaceuticals: A Handbook for Practice on a Scientific Basis. Boca Raton, Florida, USA: CRC Press 1994.

Bingel, A. and Farnsworth, N. Higher plants as potential sources of galactogogues. Economic and Medicinal Plant Research Vol.6 London: Academic Press, 1994; 1-54.

Blumenthal, M. et al. German Commission E Monographs: Therapeutic monographs on medicinal plants for human use. Austin, Texas USA: American Botanical Council, 1997.

Duke, I. CRC Handbook of Medicinal Herbs. Boca Raton, Florida, USA: CRC Press, 1985.

Farnsworth, N. Relative safety of herbal medicines HerbalGram 1993; 29:36.

Gutmanis, J. Kahuna La'au Lapa'au - The practice of Hawaiian Herbal Medicine. Aiea, Hawaii, USA: Island Heritage, 1995.

Hale, T. Medications and Mother's Milk (6th ed.). Amarillo, Texas, USA: Pharmasoft Medical, 1997.

Humphrey, S. and McKenna, D. Herbs and Breastfeeding. BREASTFEEDING ABSTRACTS Nov.1997; 17(2).

Leung, A. and Foster, S. Encyclopedia of Common Natural Ingredients Used in Foods, Drugs and Cosmetics. New York: John Wiley & Sons, 1996.

Mohrbacher, N. and Stock J. BREASTFEEDING ANSWER BOOK. Schaumburg, Illinois, USA: LLLI, 1997.

Newall, C. et al. Herbal Medicines: A Guide for Health Care Professionals. London: The Pharmaceutical Press, 1996.

Ody, P. The Complete Medicinal Herbal. London: Dorling Kindersley, 1993.

Riordan, J. and Auerbach, K. Breastfeeding and Human Lactation. London: Jones and Bartlett, 1993.

Siciliano, A. Cranberry. HerbalGram 1996:38:51-54.

Tyler, V. Herbs of Choice: The Therapeutic Use of Phytomedicinals. Binghamton, New York: Pharmaceutical Products Press, 1994.

Wagner, M. and Farnsworth, N. Economic and Medicinal Plant Research Academic Press, 1994; 1-54.

THE WOMANLY ART OF BREASTFEEDING (6th edition). Schaumburg, Illinois, USA: LLLI, 1997.

Wren, R. Potter's New Cyclopaedia of Botanical Drugs and Preparations. England: C.W. Daniel, 1988.

American Botanical Council P.O. Box 201660 Austin, Texas 78720 USA phone: (512) 331-8868 fax: (512) 331-1924

The Herb Research Foundation 1007 Pearl Street #200 Boulder, Colorado 80302 USA phone: (303) 449-2265 fax: (303) 443-0949

(These two independent nonprofit organizations are dedicated to educating the public about herbs. Together, they publish HerbalGram, a bimonthly journal reporting on recent scientific research on herbal medicinals.)

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