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50 Improvement in Lactation with Traditional Chinese Medicine and Western Herbal Medicine: A Case Study.

tudy. Journal of Chinese Medicine Number 105 June 2014

Improvement in Lactation with


Traditional Chinese Medicine
and Western Herbal Medicine:
A Case Study
Abstract
By: Britton Delayed lactation, insufficient milk supply and other breast-feeding problems are common disorders worldwide, with
R. Mann and research showing prevalence of up to 33 per cent. The aetiology of delayed lactation is multifactorial: primiparity is
Haosheng Zhang the most important contributor, but long duration of labour and inadequate breast-feeding education and support
are also factors. Conventional medical treatment focuses on early postpartum education about proper breast-
Keywords: feeding technique. In the absence of organic pathology, women may be offered pharmaceutical galactogogues,
Insufficient some of which have undesirable side-effects. This case summarises the effects of acupuncture, Chinese herbal
lactation, delayed medicine, tuina massage, cupping therapy and a Western herbal tincture on a 30 year-old primipara experiencing
onset lactation, insufficient lactation. After four weeks of treatment, the patient reported better milk production and a more positive
breast-feeding, experience of nursing, as well as improvements in other health symptoms. No adverse events were observed. The
acupuncture, authors conclude that Chinese medicine combined with Western herbal medicine may be a safe and effective
herbal medicine, treatment to address insufficient lactation and its underlying causes.
Chinese medicine.

Biomedical background quarter of American mother-infant dyads, even those


Successful breast-feeding has been linked to better highly motivated to breastfeed (Dewey et al., 2003).
health outcomes for children, particularly the Infants of mothers with delayed OL are seven times
reduction of mortality and morbidity from infectious more likely to experience excess weight loss in the first
diseases (Horta et al., 2013). Some evidence suggests weeks of life than those whose mothers have a timely
a long-term reduced risk of diabetes, obesity (Horta et onset of lactation (Dewey et al., 2003). Up to 33 per
al., 2013), childhood cancers (Martin et al., 2005) and cent of primiparas experience delayed OL, compared
atopic dermatitis (Penders et al., 2013). For mothers to only five per cent of multiparas (Dewey et al., 2003;
themselves breast-feeding is protective against Nommsen-Rivers et al., 2010). Caesarean delivery, long
breast cancer (Collaborative Group, 2002), ovarian labour, use of medications during labour (Dewey et al.,
cancer (Luan et al., 2013) and postpartum depression 2003; Nommsen-Rivers et al., 2010) and a maternal age
(Figueiredo et al., 2013). Breast-feeding also helps the greater than or equal to thirty years are risk factors for
uterus contract to its pre-pregnancy size (Holmes, delayed OL (Nommsen-Rivers et al., 2010). Obesity
2013), is useful for postnatal weight loss (Wiessinger, (Rasmussen et al., 2001), polycystic ovarian syndrome
2010) and is less expensive than infant formula. and postpartum haemorrhage (Marasco et al., 2000)
Lactation the process of milk secretion from have also been proposed as risk factors.
the breasts is a complex physiological process. Precise biomedical measurement of the successful
Successful breast-feeding relies on good physical and and timely onset of lactation is difficult, since milk is
mental maternal health, as well as the intention to transferred directly into the infant. Clinicians must
breast-feed (Hurst, 2007). A supportive family and rely on indirect measures such as maternal sensations
health-care team increases the likelihood of successful of breast fullness and nipple tingling, a feeling that
breastfeeding, as does better socioeconomic status the milk has come in and weighing infants before
(Hurst, 2007). The immediate postpartum window and after feeding (Hurst, 2007). Delayed lactation
is critical to breastfeeding success, when skin-to-skin is diagnosed when the mother reports a lack of such
contact and unrestricted access of the baby to the breast sensations and excess weight loss is noted in her infant.
are important factors (Holmes, 2013). Typical biomedical measures to address this condition
Delayed onset of lactation (OL) and suboptimal include maximising breast stimulation and complete
infant breastfeeding behaviour affect almost one- breast emptying, measuring infant milk intake,
Journal of Chinese Medicine Number 105 June 2014 Improvement in Lactation with Traditional Chinese Medicine and Western Herbal Medicine: A Case Study. 51

making a formal feeding plan and identifying the mothers corroborate the notion that such channel changes are more
maximum lactation potential (Hurst, 2007). difficult for certain women. Advanced maternal age, where
The use of pharmaceutical galactagogues (e.g. the fluidity and pliability of the channels is replaced by a
metoclopramide, a dopamine receptor antagonist) is more stagnant system against which qi and blood must
typically only recommended after treatable causes have push is one example. Long duration of labour and the use
been ruled out and education plans have failed (Zuppa et of medications during labour can both deplete and stagnate
al., 2010). There is a wealth of anecdotal reports regarding the qi prior to lactogenesis. In addition, nipple abnormality,
the effectiveness of common herbal galactogogues prior breast trauma and the presence of phlegm (common
(Forinash et al., 2012; Turkyilmaz et al., 2011), but a dearth amongst the obese) obstruct the movement of blood and
of high-quality biomedical research about even the most milk through the channels.
common preparations. The most recent systematic review
in the Journal of Human Lactation gives no recommendation
for their use (Mortel et al., 2013). It is generally accepted Subsequent to the first pregnancy, lactogenesis is like
that nearly all healthy women who experience delay can refilling a dry riverbed.
eventually produce adequate supply given the appropriate
multifaceted intervention (Chapman et al., 1999).
Based on this understanding of Chinese medical
Oriental medicine background physiology, problems with lactation can be categorised as
The jingluo, zangfu and extraordinary organs go through either excess or deficient patterns, or a combination of both.
dramatic changes during puberty and menopause. But Excess patterns involve qi stagnation, blood stasis and
compared to the abrupt physical transformations that phlegm, and tend to present with redness, inflammation,
occur during pregnancy, parturition and the onset of swelling, fever and pain (Chin, 1998). Treatment in such
lactation, these are gradual processes. Weight gain of 25 cases aims to move the stagnant qi and blood in order to
to 35 pounds is common as plasma levels increase by 50 promote lactation. Qi and blood deficiency, on the other
per cent, the placenta and foetus mature, adipose tissue hand, tends to present with fatigue, a lack of breast fullness,
builds and redistributes, the breasts enlarge, the legs retain pallor, dry skin and mucosa, and poor appetite. Treatment
water, and so forth. The yin channels of the legs, Chong in such cases involves tonifying qi and nourishing blood
mai (Penetrating vessel) and uterus receive much of this (Maciocia, 2011).
abundance in order to nurture the fetus. The traditional Chinese medicine techniques of
Immediately after parturition, blood and qi abruptly acupuncture, massage and herbal medicine have been
reroute upwards from the uterus to the breasts via proposed by a number of authors as effective treatments
the Chong mai and Stomach channel. Blood that had for insufficient lactation (as it is termed in the Chinese
nourished the foetus now becomes the substrate for milk. literature) (Neri, 2011; Zheng 2009, 2012; Mortel, 2013).
The postpartum woman experiences this as a sudden Research with high quality methodology is scarce, and thus
engorgement or fullness of the breasts, with concurrent statements about the effectiveness of these treatments for
contraction of the uterus, Chong mai and leg yin channels. insufficient lactation are difficult to make. The treatment of
Infant suckling stimulates vasoconstriction of the uterus this condition with Chinese medicine, however, has a long
(Holmes, 2014), and from a Chinese medicine perspective written history in the Chinese medical literature (Clavey,
can be likened to a siphon effect whereby blood is redirected 2003).
up and out through the nipples as milk. This rerouting
and transformation hinges on the presence of sufficient Case history
qi and blood. Qing dynasty gynaecologist Fu Qingzhu A 30 year-old primipara presented at the authors' clinic
summarised this by stating It should be understood that three weeks after vaginal delivery of a healthy, full-term
without qi, milk has nothing to transform it, and without boy. Her chief complaint was insufficient breast milk, with
blood, milk has nothing from which to be produced. (Fu, absence of the typical sensation of breast fullness expected
1992). in the days following delivery. At day three postpartum
Biomedical research describes primimarous women her baby had lost 12 per cent of his body weight, at which
as significantly more susceptible to delayed OL than point she began supplementing with formula after each
multiparous women. Chinese medical theory can explain breastfeed. At three weeks of age, her baby was adept at
this phenomenon if we consider the body as a watershed, breastfeeding and was gaining weight appropriately using
with the channels as its waterways: the first time the the additional formula, but the patient expressed interest
channels reroute, the force needed for lactogenesis is in boosting her milk supply and discontinuing formula
akin to a river cutting a new path through the landscape. supplementation. She expressed concern and feelings of
Subsequent to the first pregnancy, lactogenesis is like inadequacy that her breast milk was insufficient, describing
refilling a dry riverbed. Other risk factors for delayed OL nursing as both such a special thing and one of the most
52 Improvement in Lactation with Traditional Chinese Medicine and Western Herbal Medicine: A Case Study. Journal of Chinese Medicine Number 105 June 2014

stressful things in my life to date. Herbal treatment


Concurrent symptoms included pelvic pain and Because of the limited post-partum time-frame during
vaginal bleeding secondary to a two-centimetre posterior which lactation potential can be adjusted, we advised
episiotomy, second-degree perineal laceration and a our patient to begin taking an easily-available Western
poorly-healing left labial laceration. She experienced herbal tincture in the days preceding her first visit to our
drenching night sweats three to four times each week and clinic. Based on anecdotal reports and the time-honoured
a subjective sensation of feeling very hot with strong thirst. use of Western herbal galactogogues (Gabay, 2002), we
She described her energy levels as either low or wiped recommended an alcohol-based tincture (Lactaflow, Wise
out. She experienced pain from plantar fasciitis (rated at Woman Herbals, Oregon, USA), to be taken at a dose of two
four on a scale of one to 10) and upper back tension. The millilitres three times daily, containing:
patient also described skin pallor (perceived by her and her bitter fennel (Foeniculum vulgare)
mother) in the days following delivery, though haematocrit blessed thistle (Cnicus benedictus)
levels measured within the normal range. goats rue (Galega officinalis)
Pregnancy history was significant for anal fissures and fenugreek (Trigonella foenum-graecum)
haemorrhoids, which were provoked by constipation and fennel essential oil
accompanied by pain and rectal bleeding. At the time of her
first visit, her bowel movements were only regular with the At the patients first visit we prescribed a bulk herb (Spring
use of a stool softener. She also complained of swelling of Wind, China) modification of Shi Quan Da Bu Tang (All-
her ankles. Current medications included docusate sodium Inclusive Great Tonifying Decoction), to be decocted twice
(100mg oral BID for constipation,) a prenatal vitamin and a and imbibed as tea three times each day:
calcium plus vitamin D3 supplement. Dang Shen (Codonopsis Radix) 9g
Her past medical history included a biopsy of a lump Bai Zhu (Atractylodis Macrocephalae Rhizoma) 12g
on the left breast near the areola approximately seven Fu Ling (Poria) 12g
years prior that had been diagnosed as a fibroadenoma. Zhi Gan Cao (Glycyrrhizae Radix Preparatum) 6g
The patient tended generally towards constipation and Dang Gui (Angelicae Sinensis Radix) 15g
asymptomatic hypotension. Chuan Xiong (Chuanxiong Rhizoma) 9g
Physically, the patient appeared as a tired-looking new Bai Shao (Paeoniae Radix Alba) 15g
mother with a healthy body weight, who appeared her Shu Di Huang (Rehmanniae Radix Preparata) 15g
stated age. Her shen (visible in the eyes) was good. Her Rou Gui (Cinnamomi Cortex) 6g
pulses were thin and weak, rooted and of moderate rate. Huang Qi (Astragali Radix) 15g
Tongue examination revealed puffiness and scalloping, a Tong Cao (Tetrapanacis Medulla) 2g
pale body with a slightly red tip, and mildly engorged and
purple sublingual veins. Her complexion was pale, as were We also asked that the patient continue the Lactaflow
her inferior ocular conjunctivae. tincture twice daily, spaced between the doses of Chinese
herbal tea. Shi Quan Da Bu Tang incorporates two formulas
Diagnosis and treatment strategy appropriate for this patients condition. Si Jun Zi Tang
Based on the patients 46-hour labour and symptoms of (Four-Gentlemen Decoction) is an excellent formula for
fatigue, night sweats, delayed lactogenesis, constipation tonifying qi, whilst Si Wu Tang (Four-Substance Decoction)
and a slow-healing labial tear, we suspected a pattern of is a superior formula for nourishing blood. Also included in
qi deficiency. Signs confirming this were a puffy, scalloped the formula was sweet and warm Huang Qi, which tonifies
tongue, weak pulses and her exhausted appearance. The qi and yang, and Rou Gui, which tonifies the yang. We
patients anxiety around caregiving, tight upper back modified the formula by adding Tong Cao, a feather-light
musculature and delayed lactation were symptomatic of herb to facilitate the upward flow of Stomach qi in order to
qi stagnation. Her recent childbirth with iatrogenic and promote lactation (Bensky, 2004).
natural lacerations could easily exacerbate a pattern of
blood deficiency, and we surmised that her drenching Physical medicine treatment and
night sweats (in this case caused by qi deficiency not lifestyle adjustment
controlling the pores) were contributing to this pattern. Our primary physical medicine tools for tonifying and
We saw confirmation of the pattern of blood deficiency coursing qi were tuina massage, acupuncture and fire
in the delayed and insufficient lactation, thin pulses, pale cupping. Initially we aimed to open the channels and
skin and conjunctivae, constipation and plantar fasciitis. move qi, and to this end we used seated rolling, plucking,
To summarise, we diagnosed qi and blood deficiency, with kneading and percussion on the shoulders, neck, and upper
concurrent qi stagnation. We therefore focused treatment on back, and acupressure at Jianjing GB-21 and Tianzong SI-11.
tonifying qi and blood while freeing the flow of qi through Acupuncture was then performed using AcuTek brand
the channels. (China) 0.25 x 40mm filiform needles. We applied lifting,
Journal of Chinese Medicine Number 105 June 2014 Improvement in Lactation with Traditional Chinese Medicine and Western Herbal Medicine: A Case Study. 53

thrusting and twisting using even technique until deqi pumping more often, had introduced some solid foods into
was elicited, and retained the needles without further her babys diet, and continued to augment her own supply
stimulation for 25 minutes. The following points were with formula. Her emotional and physical experience of
selected: Jianjing GB-21, Shaoze SI-1, Tianzong SI-11, nursing was generally very good. At eight months follow-
Ganshu BL-18, Pishu BL-20, Shenshu BL-23, Taixi KID-3, up the baby measured in the 97th percentile for weight and
Taichong LIV-3, Ququan LIV-8, Hegu LI-4, Sanyinjiao SP-6, the 100th percentile for height; his diet consisted of breast
Zusanli ST-36, Qihai REN-6, Zhongwan REN-12, Tianshu milk, solid foods and approximately one bottle per day of
ST-25, Shanzhong REN-17 and Yintang M-HN-3. supplemental formula. At this visit the patient mentioned
We finished treatment with moving cupping, flash that her two prior menstrual bleeds corresponded with
cupping and massage with the warmed cups along the a decrease in her milk supply, which would then recover
Bladder, Small Intestine and Gall Bladder channels of the at cessation of bleeding. After her most recent menses,
upper back and shoulders in order to relax the musculature however, her milk had stopped flowing entirely. The
and unbind qi. patient was given one further acupuncture treatment and
The patient had already received appropriate instruction re-started on a decoction of Shi Quan Da Bu Tang, after
from the lactation consultants at her birthing hospital which her milk supply returned to normal.
regarding skin-to-skin contact with her baby, frequent
feeding and the use of a breast pump. To augment this
education, we instructed the patient to apply hot water Even an uncomplicated childbirth precipitates some degree
compresses over her breasts in order to facilitate the flow of
of qi and blood deficiency in the postpartum woman.
qi, blood and milk. We also recommended that her husband
should apply nightly acupressure at Jianjing GB-21 and
Tianzong SI-11. For dietary augmentation we suggested
bone broth soup to nourish blood and fluid. We emphasised Discussion
the importance of rest and suggested she return for weekly Though the outcome for this patient was mostly favourable,
treatment at our clinic. Given her tendency towards feelings we believe that the three-week postpartum delay in
of inadequacy, the overwhelming emotional experience of implementing a comprehensive intervention to boost her
becoming a parent, and the physical and logistical burdens milk supply may have hampered her ability to breast-feed
of caring for a newborn, we asked that she do her best to exclusively. Though we believe our treatment was beneficial
integrate our treatment suggestions without imposing to her milk supply, we recognise that in the natural course
undue self-pressure (in order to avoid compounding her of healing from labour and delivery there can be a natural
existing qi stagnation with a list of unattainable demands). remission of symptoms and increase in lactation.
The diagnosis and successful treatment of insufficient
Outcomes breast milk has a long history in the Chinese medical
We saw this patient four times in our clinic over five weeks. literature (Clavey, 2003), and yet a literature review
Over the initial two weeks of treatment, the patient reported returns few reports of the use of acupuncture or herbs to
increasing breast fullness and nipple leakage. She was able benefit lactation. We found no research documenting the
to reduce and eventually cease supplemental feeding with combined use of traditional Chinese medicine and Western
formula. During the third to the fifth weeks of treatment, herbal medicine. Based on the historical record and our
however, the patient reported inconsistent compliance with clinical experience, however, we believe these therapies are
the herbal medicine and was unable to attend the clinic, under-utilised in the treatment of delayed and insufficient
which resulted in a two-week hiatus between visits. At this lactation. The case outlined here provides evidence that
time, despite her increased milk supply, her paediatrician Chinese medicine and Western herbal medicine are safe
recommended restarting formula supplementation methods to increase lactation capacity in new mothers.
because of slowed weight gain in the baby. The patients According to traditional Chinese medicine theory, even
secondary symptoms of foot pain, night sweats, subjective an uncomplicated childbirth precipitates some degree of qi
heat sensation, constipation and vaginal bleeding had been and blood deficiency in the postpartum woman. Chinese
largely resolved by this time. She noted plentiful energy medicine considers blood to be the material basis for breast
and good mood. Her skin was lustrous, her tongue and milk, and milk as transubstantiated blood (Chin, 1998). Qi
conjunctivae were pink, the tongue body remained slightly is the power behind this transformation. Thus treatment
puffy but was without scalloping, and her pulse had of insufficient lactation must necessarily address both
adequate volume. We gave her one more week of modified qi and blood deficiency. The preeminent Qing dynasty
Shi Quan Da Bu Tang, and asked that she continue the gynaecologist Fu Qingzhu summarised this as follows: In
Lactaflow tincture for maintenance of her supply. the newly birthed woman, blood is too depleted to look
At four-month follow-up, the patient reported a good after itself. [Therefore,] how can it transform [into] milk? It
milk supply, despite having returned to work. She was is entirely due to the strength of the qi that blood is moved to
54 Improvement in Lactation with Traditional Chinese Medicine and Western Herbal Medicine: A Case Study. Journal of Chinese Medicine Number 105 June 2014

transform [into] milk. (Fu, 1992). This quotation highlights comes as no great surprise, given that high motivation is
the importance of qi for the production of blood. Blood often paired with anxiety. We believe that in the context
is yin substance and takes time to produce. Thus, simply of the labile postpartum period, qi can easily bind and
administering high doses of blood tonics after birth will inhibit the let-down of milk. When considering treatment,
not necessarily restore blood in the timeframe necessary for interventions chosen for postpartum women should be
lactogenesis. Qi is yang in nature and can be augmented attainable without adding undue stress or complication.
quickly. The simple structure of Dang Gui Bu Xue Tang Complicating this treatment picture is the critical
(Tangkui Decoction to Tonify the Blood) - with five parts importance of the immediate postpartum window for
Huang Qi (Astragali Radix) to one part Dang Gui (Angelicae establishing a plentiful milk supply. Interventions should
sinensis Radix) - suggests that qi fortification is essential to be put into effect quickly for optimal outcomes. The most
the restoration of blood. Additionally, we should take into comprehensive strategy should include all members of a
account the Nei Jing Su Wen (Yellow Emperors Classic of patients health-care team as well as her family.
Internal Medicine Basic Questions) chapter five, in which it
is stated, Shao huo sheng qi (Temperate physiologic fire Conclusion
generates qi [author translation]). This means that yang Lactogenesis is a complex process that occurs during a
underpins qi, and thus treatment of qi deficiency should radically transformative period in a womans life. Western
incorporate yang tonification. and Chinese models of physiology and pathology of
Shi Quan Da Bu Tang is a good choice for deficient breastfeeding demonstrate remarkable congruency.
postpartum patients because it emphasises qi and yang Clinicians with both Chinese and biomedical perspectives
as well as blood tonification. Within it, Si Wu Tang (Four can closely monitor patients with known risk factors for
Substance Decoction) nourishes blood and Si Jun Zi Tang delayed onset of lactation and offer effective intervention.
(Four Gentlemen Decoction) nourishes qi. The addition of Acupuncture, physical medicine (i.e. massage, cupping,
Rou Gui (Cinnamomi Cortex) stokes the physiologic fire compresses etc.), Western herbs and Chinese herbal medicine
referenced in the Nei Jing, and Huang Qi (Astragali Radix) can be helpful interventions for insufficient lactation. With
assures qi is sufficient so that blood is promoted from the proper diagnosis and treatment, these modalities can help
stickier tonic herbs. boost milk supply and resolve the underlying pathologies.
We must also note that sweat is transformed from blood. We suggest that by combining Chinese medicine channel
The progression from excess sweating to insufficient theory with known biomedical risk factors for delayed OL,
lactation has been recorded in the Chinese medical postpartum patients can be more effectively monitored for
literature (Clavey, 2003), and this condition must be signs of lactation problems. We are aware of the limitations
addressed in treatment. Qi tonification (where correctly of this case study, and recommend more rigorous research
applied) can regulate sweating, protect blood and to evaluate these treatment approaches. Given the
subsequently increase milk production. Tangentially, the preponderance of lactation problems in the population,
biomedical understanding that the mammary gland is a especially among primiparas, and the myriad benefits
modified sweat gland supports our concern for this aspect from breast-feeding, more research into this condition will
of physiology (Mortel et al., 2013). promote public health.
Qi stagnation also contributes to lactation difficulty.
Zhang Congzheng wrote about this phenomenon in his Jin- Biographies
Yuan dynasty text Ru Men Shi Qin (A Scholars Duty to His Britton Mann is a licensed acupuncturist providing acupuncture
Parents, 1994): and Chinese herbal medicine at Haosheng Acupuncture Clinic in
Portland, Oregon. He holds a Master of Science in Oriental Medicine
. from the National College of Natural Medicine (Portland, OR), and
(Ru zhi bu xia: huo yin ti ku, bei nu yu jie, qi yi is currently pursuing a Doctorate in Acupuncture and Oriental
bi se, yi zhi ru mai bu xing.). Medicine at the Oregon College of Oriental Medicine (Portland,
Milk is not able to descend [i.e. there is no lactation]: OR). He may be contacted at britton@metoliusnaturalmedicine.com.
reasons for this are crying, grief and anger that leads
to qi stagnation, overflowing of qi, congealed qi and Haosheng Zhang graduated in 1984 with a Masters degree from
obstructed qi causing impediment in the breast channels Chengdu University of Traditional Chinese Medicine, China. He was
[Author translation]. an associate professor and deputy director of the teaching and research
department of Wen Bing Xue (Warm Disease School), and successor
Postpartum women experience heightened emotions, and to Master Zhiwen Zhangs lineage. He has been practising Chinese
insufficient milk supply can compound feelings of maternal medicine for almost three decades. From 1997-2012 he was academic
inadequacy. Western medical literature reports that the and clinical faculty at the National College of Natural Medicine in
strong determination to breastfeed is not protective against Portland, Oregon. He has a private practice at Haosheng Acupuncture
early breastfeeding problems (Dewey, 2003). This paradox Clinic, and may be contacted at info@haoshengacupuncture.com.
Journal of Chinese Medicine Number 105 June 2014 Improvement in Lactation with Traditional Chinese Medicine and Western Herbal Medicine: A Case Study. 55

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