Maternal Milk Supply Research Articles

Understanding modifiable barriers to human milk donation in the United Kingdom.

When premature infants cannot receive their own mother's milk, donor human milk (DHM) is the first-line recommended option, with growing demand for DHM use outside of neonatal units. To meet the potential need, we need to consider whether DHM supply can increase. This study aimed to explore the reasons that prevent women who wish to donate their milk in the United Kingdom from doing so to understand which barriers may be modifiable. Women who wanted to donate their milk but did not do so completed an online survey. Open and closed questions examined the response they received, their reasons for not donating and what they did with any milk that they had already stored. Out of 732 mothers, 391 (53.4%) did not enquire as they did not think it was possible for them, 218 (29.8%) enquired but were told that they could not donate, 59 (8.1%) enquired but decided not to proceed and 64 (8.7%) received no response. Reasons for being told they could not donate included the use of certain medications, infant age, inadequate staffing, geographic barriers and incorrect storage. Process aspects (e.g., blood tests, practicalities) and lifestyle limitations led mothers to decide not to donate. Although some women will be prevented from donating due to medication or health issues, investment in milk banking staffing and infrastructure and awareness campaigns could increase DHM supply, enabling guidelines to extend eligibility criteria for receiving DHM such as for late preterm infants, gestational diabetes or to support low maternal milk supply.

Effect of brewer’s yeast or beta-glucan on breast milk supply following preterm birth: the BLOOM study – protocol for a multicentre randomised controlled trial

BackgroundMany individuals who experience preterm birth struggle with early breast milk supply, which can translate into suboptimal longer-term breastfeeding outcomes. Further investigations into the potential role of early non-pharmacological and pharmacological interventions in improving breast milk production soon after birth is growing. While natural galactagogues, such as brewer’s yeast, are widely perceived by women to be safer than pharmaceutical galactagogues and are taken by many women, evidence to support their efficacy is largely absent. The BLOOM study has been designed to determine the efficacy and safety of brewer’s yeast and beta-glucans, derived from Saccharomyces cerevisiae, when administered soon after birth for increasing early breast milk supply in mothers who have delivered preterm.MethodsThe BLOOM study is a multicentre, double-blinded, randomised controlled trial that will assess if brewer’s yeast or beta-glucan can increase early breast milk production following preterm birth. Target population are mothers of preterm infants born at less than 34 weeks’ gestation who intend to provide breast milk for their infant, are less than 72 h following birth and able to give informed consent. Participants will be randomly allocated into three parallel groups at 1:1:1 ratio (n = 33 per group) to receive either brewer’s yeast, beta-glucan or placebo capsules for seven days. The primary outcome is total expressed breast milk volume over a 24-hour period on day 7 of intervention. Participants and their infants will be followed until the infant reaches term corrected age or is discharged home from the neonatal unit (whichever occurs first).DiscussionThe use of brewer’s yeast as a galactagogue to enhance milk production is extremely common amongst breastfeeding mothers, however, there are no trials evaluating its efficacy and safety. This will be the first randomised controlled trial to evaluate the efficacy and safety of two commonly used galactagogues, brewer’s yeast and beta-glucan, compared with placebo in improving maternal breast milk supply following preterm birth. The trial will also evaluate whether early intervention with galactagogues soon after a preterm birth improves longer-term breastfeeding outcomes.Trial registrationAustralian and New Zealand Clinical Trials Registry ACTRN12622000968774 (registered on 8 July 2022) and UTN U1111-1278-8827.

Circumstantial: An Evaluation of Circumcision, Breastfeeding, and Overall Dyad Success.

Circumstantial: An Evaluation of Circumcision, Breastfeeding, and Overall Dyad Success.

Lifelong Impact? The Effect of Phototherapy Admission on Future Breastfeeding.

Lifelong Impact? The Effect of Phototherapy Admission on Future Breastfeeding.

Breastfeeding and drugs

Key content Most commonly used medications such as paracetamol, most antibiotics and inhalers are considered safe for women to use during lactation. Most drugs taken by a breastfeeding woman will be expressed in small volumes in the breast milk. The amount depends on several factors, including the drug dose, the size of the molecule, the protein binding and lipid solubility of the drug, the age of the infant and volume of milk consumed. Data regarding short‐term and long‐term effects of maternal medication use on breastfed infants are limited. There is no direct evidence of impaired lactation with most commonly used medications, but some medications, such as decongestants (pseudoephedrine/phenylephrine), high‐dose diuretics and the combined oral contraceptive pill, may inadvertently adversely affect maternal milk supply. Women need accurate and balanced advice regarding safety of medication in breastfeeding to avoid early or inappropriate cessation of medications in the lactation period. Learning objectives Understand the pharmacokinetics of common medications used in the lactation period. Understand the impact of drugs on the breastfed infant. Be familiar with the current literature on drug safety and lactation to enable appropriate counselling.

Case 2: Feeding Intolerance Following Topical Atropine Instillation in a Premature Infant

An extremely low-birthweight female newborn, weighing 545 g, is born at 23 weeks of gestation via cesarean section. Following a pregnancy complicated by preterm labor with prolonged rupture of membranes and positive maternal group B Streptococcus status, the newborn requires positive pressure ventilation, chest compressions, intubation, and surfactant administration in the delivery room. After initial stabilization, she is admitted to the NICU. She receives continuous positive pressure ventilation on day 37 after birth and is ultimately weaned to room air. She initially receives enteral feeds with breast milk and gradually advances to full enteral feeds by day 40 after birth. Within a week of tolerating full enteral feeds, she makes a transition to 24 kcal/oz of formula because of insufficient maternal breast milk supply. Her eyes are regularly screened for retinopathy of prematurity (ROP) from 31 weeks’ postmenstrual age (PMA). Before each ROP screening, she receives cyclopentolate/phenylephrine and proparacaine ophthalmic eye drops. Her initial eye examination reveals bilateral zone 1 stage 1 ROP. After the diagnosis of bilateral zone 2 stage 3 ROP with plus disease is made at PMA of 36 weeks, she is successfully treated with laser ablation therapy to the peripheral avascular retina of both eyes after a brief period of having nothing orally for 4 hours. Her enteral feeds are resumed later on the same day after laser surgery. She is subsequently started on daily ophthalmic 0.5% atropine drops and tobramycin/dexamethasone ophthalmic drops 4 times a day. On postoperative day 1, she is noted to have tachycardia with pulses ranging from 190 to 200 beats/min 1 hour after ophthalmic atropine is applied. She continues to have intermittent tachycardia, but enteral feeds are continued as she continues to have normal physical examination …

The Safety of Mother's Milk® Tea: Results of a Randomized Double-Blind, Controlled Study in Fully Breastfeeding Mothers and Their Infants.

Various natural products are reported to improve maternal milk supply yet are not necessarily safe for infants. Researchers have not systematically studied galactagogue teas for safety. This study evaluates the safety of a galactagogue tea in breastfeeding women and their infants, assessing short- and long-term adverse effects. Healthy, exclusively/fully breastfeeding women ( N = 60) with no milk insufficiency were randomized into (1) an all-natural tea containing fruits of bitter fennel, anise, and coriander; fenugreek seed; and other herbs (Mother's Milk® herbal tea; test) group or (2) a lemon verbena leaf (placebo) group. Maternal diaries captured self-reported maternal and infant adverse effects, tea consumed, and perceived infant satisfaction. Maternal quality of life and psychological state were assessed at baseline and 2 and 4 weeks. Poststudy calls assessed adverse effects through the infants' age of 12 months. No adverse effects attributable to the interventions were reported at any time point. No differences were found between test and placebo groups in sociodemographic characteristics, maternal or infant adverse symptoms, quality of life, breastfeeding self-efficacy, maternal psychological measures, infant growth, and infant satisfaction (all p >.05). This double-blind, randomized controlled trial (RCT) of an herbal galactagogue versus placebo among healthy, exclusively/fully breastfeeding mothers and infants found no adverse events associated with the test tea across the 30-day study or the first year of their infant's life. This composite tea appears to present no safety risk for mothers or their young babies.

SPN Position Statement: The Role of Pediatric Nurses in the Promotion and Protection of Human Milk and Breastfeeding

SPN Position Statement: The Role of Pediatric Nurses in the Promotion and Protection of Human Milk and Breastfeeding

Perceived Maternal Behavioral Control, Infant Behavior, and Milk Supply: A Qualitative Study.

Disparities persist in breastfeeding exclusivity and duration despite increases in breastfeeding initiation. The objective of this study was to examine factors that influence maternal decision making surrounding infant feeding practices over time in a diverse inner-city population. We conducted a prospective qualitative study with 20 mothers recruited from 2 urban primary care clinics. Participants completed open-ended interviews and demographic questionnaires in English or Spanish administered at approximately 2 weeks and 6 months postpartum. Transcripts were analyzed using a combined technique of inductive (data-driven) and deductive (theory-driven, based on the Theory of Planned Behavior) thematic analysis using 3 independent coders and iterative discussion to reach consensus. All women initiated breastfeeding, and 65% reported perceived insufficient milk (PIM). An association between PIM and behavioral control emerged as the overarching theme impacting early breastfeeding cessation and evolved over time. Early postpartum, PIM evoked maternal distress-strong emotional responses to infant crying and need to control infant behaviors. Later, mothers accepted a perceived lack of control over milk supply with minimal distress or as a natural process. Decisions to stop breastfeeding occurred through an iterative process, informed by trials of various strategies and observations of subsequent changes in infant behavior, strongly influenced by competing psychosocial demands. Infant feeding decisions evolve over time and are influenced by perceptions of control over infant behavior and milk supply. Tailored anticipatory guidance is needed to provide time-sensitive strategies to cope with challenging infant behaviors and promote maternal agency over breastfeeding in low-income populations.

Promoting Breast Milk Nutrition in Infants With Cleft Lip and/or Palate

To the Editor: Burca and colleagues1 are to be congratulated for their efforts to promote breast milk for infants with cleft lip and/or cleft palate (CL/P). They nicely outline the important benefits of breast milk for this vulnerable population, and we commend the authors for their position that human milk “should be central to the care of these infants.” However, we are concerned with several recommendations related to how human milk is delivered. First and most concerning is the statement by the authors that “breastfeeding usually/sometimes works well” for an infant with a cleft palate and recommendations in this regard (see Table 1 in Burca et al1). We caution the authors to avoid giving the impression that children with isolated cleft palate are likely to feed effectively or fully at the breast. The vast majority of children with a cleft palate do not feed well at the breast and require an adaptive feeding method. Efforts should focus on ways to improve availability of breast milk for these patients, beginning with support and education of parents during the prenatal visit, and continuing through the perinatal period and infancy. The advice that an infant with a cleft palate can breastfeed shows a misunderstanding of the sucking mechanics of an infant with a cleft palate, which is distinct from an infant with a cleft lip. As the authors point out, an infant with a cleft lip and intact palate will most likely be able to feed at the breast effectively. A lactation consultant can assist the mother with positioning to assist with lip seal, which often, but not always, allows breastfeeding. With a cleft palate, the infant is unable to generate sufficient intraoral suction to breastfeed effectively. Regardless of size or location of the cleft palate (as stated in the article), the presence of the cleft palate prohibits the infant from isolating the oral cavity from the nasal sinuses, thereby preventing the infant from developing the negative pressure vacuum needed to draw milk from the breast.2 There are only extremely rare cases where the mother and infant can work together so the infant may feed directly and fully from the breast. Second, the authors state that “infants with CL/P consume less milk, gain less weight, and measure lower on growth curves” than infants without CL/P. Nutrition in children with oral clefts has not been well studied. There are many potential confounders that impact the published studies suggesting suboptimal growth in children with clefts, and some studies have shown that children with clefts do have adequate growth whether or not the palate is involved.3 Given the mostly small or anecdotal studies in this field, the reason for poor growth may stem from infants who are not given appropriate feeding methods to compensate for the cleft or have other malformations or medical problems leading to inadequate nutritional status. Most infants with clefts who are managed with the proper feeding tools grow at the same rate as an infant without a cleft. Numerous adaptive bottles are available for infants with clefts, which assist with milk flow so the infant can feed well without needing to create a vacuum. Assistive devices may also be used at the breast but require careful instruction to ensure adequate milk intake. If there is a delay in diagnosing the cleft palate or implementing the correct feeding adaptation, there will be a risk of infant weight loss and diminishing maternal milk supply if milk expression is not started quickly after birth. Lastly, the authors state that “feeding human milk by bottle is the preferred approach if direct breastfeeding is not possible.” This is true for infants in high-resource settings. In low-resources settings, however, the World Health Organization and United Nations Children's Fund4,5 recommend cup feeding for infants unable to breastfeed as the safest tool. Because 94% of children born with an oral cleft are born in a developing country,6 this advice should be included in guidance on adaptive equipment to support feeding. We do applaud the authors for their efforts but believe it is imperative that the clinical community clearly understand the differences in the potential for infants with various types of clefts to feed at the breast. What does not differ is the ability of these infants to benefit from breast milk feeding. Future efforts should focus on interventions to support mothers in providing this valuable source of nutrition to their infants. Emily Gallagher, MD, MPH [email protected] Christy McKinney, PhD, MPH Robin Glass, MS, OTR, IBCLC Seattle Children's Hospital Craniofacial Center,Seattle, Washington

Breastfeeding Continuation Among Late Preterm Infants: Barriers, Facilitators, and Any Association With NICU Admission?

Late preterm birth (at 34-36 6/7 weeks' gestation) is a risk factor for early breastfeeding cessation. The objective of this study was to determine barriers to and facilitators of breastfeeding continuation among late preterm infants (LPI) and to compare the barriers faced by LPI admitted to the well nursery versus the NICU. The SAS Complex Survey was used to perform multivariable logistic regression analysis by using data from the Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System. Data from 3 states (Illinois, Maine, and Vermont) for the years 2004 to 2008 were used. A total of 2530 mothers of LPI were surveyed. Odds of breastfeeding initiation were similar among LPI admitted to the NICU versus the well nursery (adjusted odds ratio, 1.24 [95% confidence interval, 0.88-1.73]; P = .209). Odds of breastfeeding for ≥ 10 weeks were no different between LPI admitted to the NICU versus those admitted to the well-nursery (adjusted odds ratio, 1.02 [95% confidence interval, 0.73-1.43]; P = .904). Factors associated with increased odds of breastfeeding for ≥ 10 weeks among LPI were higher maternal education, mother being married, and normal maternal BMI. Regardless of NICU admission, the top reasons cited by mothers of LPI for early breastfeeding discontinuation were perceived inadequate milk supply and nursing difficulties. Among LPIs, NICU admission was not associated with early breastfeeding cessation. Mothers of LPIs with lower odds of sustaining breastfeeding for at least 10 weeks were single mothers, those with a high school education only, and those who were obese. Breastfeeding support should be enhanced for LPIs and should address perceived maternal milk supply concerns and nursing difficulties.

Allosuckling in reindeer (Rangifer tarandus): A test of the improved nutrition and compensation hypotheses

The hypothesized causes and functions of allosuckling can co-occur and influence each other (i.e., non-mutually exclusive). In our two previous studies of allosuckling in reindeer, Rangifer tarandus, the milk-theft and reciprocity hypotheses were supported; the mismothering hypothesis received partial support; and the kin-selection hypothesis was not supported. In this study we investigated: the compensation hypothesis, stating that offspring may allosuckle to compensate for low birth mass, insufficient maternal milk supply (i.e., high maternal rejection rates, low mass of mothers and a large number of allonursing bouts performed by a calf's mother) or inadequate growth; and the improved nutrition hypothesis, stating that offspring improve their nutrition, and hence mass gain, by ingestion of non-maternal milk in addition to maternal milk. For the compensation hypothesis, we predicted that: (1) the cumulative number of allosuckling bouts performed by a calf (hereafter, number of allosuckling bouts) would increase due to low birth mass of calves and other measures of insufficient maternal milk supply; (2) the percentage of mass gain would not be related to the number of allosuckling bouts (i.e., calves that allosuckled often would have the same percentage of mass gain as calves that allosuckled less often) or would have a negative relationship with the number of allosuckling bouts (i.e., calves that allosuckled often would have a lower percentage of mass gain than calves that allosuckled less often); and (3) a negative relationship between the percentage of mass gain and the number of allosuckling bouts would vary with birth mass. For the improved nutrition hypothesis, we predicted that the percentage of mass gain of calves that allosuckled often would increase more than for calves that allosuckled less often. We tested the compensation and improved nutrition hypotheses on 25 mother–calf pairs of semi-domesticated reindeer from parturition to 67 days of age of calves. The number of allosuckling bouts was not influenced by low birth mass of calves or other measures of insufficient maternal milk supply. Percentage of mass gain increased as the number of allosuckling bouts increased. Calves born heavier had a lower percentage of mass gain than calves born lighter. The relationship between percentage of mass gain and number of allosuckling bouts did not vary with birth mass. Our findings did not support the compensation hypothesis. Our results suggest that allosuckling functioned to improve nutrition by ingesting non-maternal milk in addition to maternal milk, which increased the percentage of mass gain.

Minimizing Patient Safety Events Through a Multidisciplinary Approach to Human Milk Management

Optimization of nutrition is key in infant development and it is well documented that human milk is the ideal form of nutrition for infants during the first year of life. However, unaltered maternal human milk may not be sufficient to meet the nutritional demands of premature infants. Under these circumstances, addition of a fortifier to the maternal human milk has become standard practice. In one newborn/infant intensive care unit (N/IICU) located in Philadelphia, fortification and modification of human milk is handled within the Human Milk Management Center (HMMC). A multidisciplinary team rounds weekly on all infants receiving fortified or modified human milk. Feeding orders and maternal milk supply are discussed to ensure the feeding is ordered correctly, the final caloric concentration is correct and a backup feeding order is in place for low maternal milk supply. Through this multidisciplinary discussion, the team has been able to identify and resolve potential errors from reaching the patient. Improvement in patient safety while providing human milk remains of utmost importance and the central goal of the HMMC collaborative.

Formula Supplementation of Breastfed Infants

Formula supplementation of the breastfed infant is engaged in for numerous reasons, many of which are not evidence based. While clinicians and mothers may view this practice as a benign intervention, there are a number of undesired side effects of which parents and health care providers may be unaware. These side effects can result in adverse outcomes on the maternal milk supply, on the duration and exclusivity of breastfeeding, and on the infant’s gut microbiome. Alterations of the neonatal gut environment from formula supplementation can be responsible for mucosal inflammation and disease, autoimmunity disorders, and allergic conditions in childhood and adulthood. Soy infant formula can contain genetically modified ingredients and present a food with lower nutritional quality. Careful assessment and interventions that are designed to produce outcomes of abundant milk production and rapid resolution of breastfeeding problems help preserve the exclusive breastfeeding experience and result in optimal health outcomes for mothers and their infants.

Evidence of Improved Milk Intake After Frenotomy: A Case Report

Ankyloglossia (tongue tie) is a well-recognized cause of breastfeeding difficulties and, if untreated, can cause maternal nipple pain and trauma, ineffective feeding, and poor infant weight gain. In some cases, this condition will result in a downregulation of the maternal milk supply. Milk-production measurements (24-hour) for a breastfeeding infant with ankyloglossia revealed the ineffective feeding of the infant (78 mL/24 hours), and a low milk supply (350 mL/24 hours) was diagnosed. Appropriate management increased milk supply (1254 mL/24 hours) but not infant milk intake (190 mL/24 hours). Test weighing convincingly revealed the efficacy of frenotomy, increasing breastfeeding milk transfer from 190 to 810 mL/24 hours. Postfrenotomy, breastfeeding almost completely replaced bottle-feeding of expressed breast milk. This case study confirms that ankyloglossia may reduce maternal milk supply and that frenotomy can improve milk removal by the infant. Milk-production measurements (24-hour) provided the evidence to confirm these findings.

Strategies to Increase Milk Volume in Mothers of VLBW Infants

The provision of breast milk to premature VLBW infants is associated with significant health benefits. Unfortunately, the delivery of breast milk to these vulnerable infants is often limited due to insufficient maternal milk supply. Several interventions have been investigated with respect to increasing milk volume in mothers of VLBW infants but confusion exists concerning the interventions' effectiveness. The purpose of this systematic review is to critique the evidence regarding specific milk expression strategies that aim to improve milk volume in mothers of VLBW infants.Published article references, electronic databases, dissertations and theses, and select conference proceedings were searched with the goal of finding studies that target VLBW infants and milk expression techniques in which breast milk volume was an outcome. Analysis of evidence revealed an association between increased milk volume and early initiation of expression, increased frequency of expression, and provision of kangaroo care. The use of simultaneous or sequential milk expression and duration of milk expression sessions were not found to significantly improve milk volume. These results may be used to formulate specific strategies designed to increase breast milk volume in this population.

A Case Study of a Late Preterm Infant’s Transition to Full At-Breast Feedings at 4 Months of Age

Breast milk intake is recommended for late preterm infants. Many mothers provide expressed breast milk during hospitalization and anticipate transitioning their late preterm infant to full feedings at-breast after discharge. However, some infants take months to transition to full feedings at-breast. This article describes the case of a mother and her 35-week infant who transitioned to full feeding at-breast at 4 months after discharge. The clinical strategies to maintain maternal milk supply, use of hospital-grade scale, and importance of professional and community lactation support are discussed.

Nutrient density in complementary feeding of infants and toddlers

The paradigm of the first 1000 days of life, the period from conception to the second birthday, has been advanced as a critical window of opportunity to save a life and a child's future. Infancy and toddler life, through the first 24 months after birth, is a unique period during which human milk is recommended as either the exclusive source of nutrition (6 months) or a variable component thereof. After the maternal delivery of milk is accounted for, the remainder of the energy and nutrients needs come from complementary foods. There is an intrinsic gap left by the maternal milk supply in volume and micronutrient content in relation to expanding infant and toddler needs. The nutrient density approach provides us with a mathematical framework to manage the closing of the nutrient gap. The intrinsic nutrient content of the unprocessed foods appropriate for young children is limited. The most problematic nutrients are calcium, iron and zinc. Some manner to enhance the nutrient density of the complementary foods is an incontestable necessity. The nutrient density consideration, which identifies for us the nature of the problem, offers a tool for the titrating of the fortification to an adequate--but safe--addition.

The American Academy of Pediatrics and Breastfeeding

Breastfeeding MedicineVol. 7, No. 5 The Call to Action: Has Anyone Answered?The American Academy of Pediatrics and BreastfeedingO. Marion BurtonO. Marion BurtonSearch for more papers by this authorPublished Online:27 Sep 2012https://doi.org/10.1089/bfm.2012.0096AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetailsCited byPerceived Maternal Behavioral Control, Infant Behavior, and Milk Supply: A Qualitative StudyJournal of Developmental & Behavioral Pediatrics, Vol. 38, No. 6Limited infant exposure to benznidazole through breast milk during maternal treatment for Chagas disease10 September 2014 | Archives of Disease in Childhood, Vol. 100, No. 1Necrotizing Enterocolitis: The Mystery Goes On20 August 2014 | Neonatology, Vol. 106, No. 4 Volume 7Issue 5Oct 2012 InformationCopyright 2012, Mary Ann Liebert, Inc.To cite this article:O. Marion Burton.The American Academy of Pediatrics and Breastfeeding.Breastfeeding Medicine.Oct 2012.334-336.http://doi.org/10.1089/bfm.2012.0096Published in Volume: 7 Issue 5: September 27, 2012Online Ahead of Print:September 4, 2012PDF download

Management of Deficient Lactation in Switzerland and Canada: A Survey of Midwives' Current Practices

Support and promotion of breastfeeding are important healthcare issues and a global priority. In the United Nations Chronicle, it states that exclusive breastfeeding for the first 6 months is the ideal. In addition, timely and appropriate complementary feeding from 6 months of age and continued breastfeeding up to 2 years of age and beyond are also recommended. Initiatives for promotion of breastfeeding have also led to the creation of international guidelines such as the strategies proposed by The National Institute for Health and Clinical Excellence for the support of appropriate infant and young child feeding, especially in the first 2 years of life. However, lactation management protocols do not contain clear guidelines for the treatment of insufficient or deficient lactation. Midwives play a key role in educating and supporting mothers regarding human lactation and infant feeding. Despite international efforts to promote breastfeeding, the management of insufficient lactation may differ among countries because of differences in health policies and legislation, as well as in midwife status. Sustainable breastfeeding depends on multiple physiologic and psychosocial factors. Early recognition of risk factors is critical for clinicians who interact with breastfeeding women so that intervention can take place and achievement of full or partial breastfeeding can be preserved. Instruction and optimization of lactation techniques constitute primary interventions to maximize maternal lactation capacity. When these techniques prove to be insufficient, different galactagogues such as medicinal plants/foods, homeopathy, or medication are sometimes recommended. No systematic studies have evaluated the safety or efficacy of lactogenic herbs/foods or homoeopathic remedies, although the traditional use of these plants suggests that they are relatively safe to use and may be effective. We conducted a survey (a convenience sample), to analyze midwives’ current practice for the initiation or augmentation of maternal milk supply in Switzerland and Canada. We used an online anonymous survey during March 2009 in both countries and collected the following information from participating midwives: Types of practices, number of breastfeeding women requiring use of galactogogues, treatment recommendations, and local or national management policies. In Switzerland, 351 of 700 (50%) midwives and in Canada 80 of 175 (46%) completed the questionnaire. The majority of respondents (93% in Switzerland and 100% in Canada) reported their patients sometimes require the use of galactagogues, as well as the following: Instruction of breastfeeding techniques (100% in Switzerland and Canada), lactogenic herbs/foods (96% in Switzerland and Canada), homeopathy (46% vs. 4%), acupuncture (39% vs. 3%), and medication (16% vs. 68%). Only 14% of the respondents in Switzerland and 26% in Canada reported that they followed an official protocol or national guideline. To our knowledge, this is the first study that attempts to provide an overview of current practices in this important field. Mothers report that insufficient milk supply is a reason for discontinuing breastfeeding, and our results confirm this. In our survey, recommended breastfeeding techniques, as suggested by the previously mentioned guidelines, were the preferred and first-line support advised by the respondents. Thus, international guidelines appeared to be applied to maximize maternal lactation capacity, although only a small percentage of respondents stated that they actually work with these protocols in everyday practice. When breastfeeding techniques were considered ineffective to correct insufficient lactation, a majority of the respondents from both countries recommended the use of galactagogues. It is interesting that many of the respondents from both countries considered, on an empirical basis, that herbal preparations as well as pharmaceutical compounds were effective in increasing lactation, which may explain why galactagogues were used on a fairly regular basis by the midwives. The galactagogues most frequently recommended by the Swiss respondents were lactogenic herbs/food, homeopathic remedies, and acupuncture (Table 1); Canadian respondents also recommended herbs/food but did not appear to be as familiar with homeopathic galactagogues or acupuncture, and domperidone was more often advised. Conversely, intranasally administrated oxytocin was the most frequently used medicinal galactogogue by the Swiss midwives. This study had several limitations, so caution should be used when interpreting the results. The midwives who