Spotlight on Fenugreek - Does natural always equal safe?

There often seems to be an assumption that if something is derived from a plant or herb - it is  safe, or at least safer than a pharmaceutical drug because it's natural.  Often there is little consideration given to the side effects of a natural supplement, nor potential interaction with other prescribed medications.

Galactogogues - something taken to try and help increase milk supply, seems to be one area where this is so.  Many look to herbal options such as fenugreek, blessed thistle and goats rue, before considering a pharma drug such as domperidone (Motilium); with some suggesting it's better for parents to try the natural option before moving onto medicine.

The trend also extends to the "mummy market" - breastfeeding teas and lactation cookies, some claiming to be miracle supply boosters (but more about that in a minute) can be purchased, containing the above ingredients.

But is it really as clear cut as natural is good, pharma is bad?

I thought I would start the "spotlight on" section with probably the most common UK galactagogue.

Fenugreek

Fenugreek has used both as a herb (the leaves) and as a spice (the seed) since ancient times. Some charred seeds have been dated as 4000 BCE and reports state desiccated seeds were also found in the tomb of Tutankhamen.

Fenugreek is a commonly used flavouring agent in curries, chutneys/pickles as well as sprouted and eaten as a salad. It is used as a dye and also medicinally in some areas; drinking a cup of fenugreek tea per day made from the leaves, is said to relieve the discomfort of arthritis and others report its effectiveness when applied to eczema (there are lots of other reported medical uses too from reducing cholesterol levels to relieving gastric discomfort).

Something used in food is therefore bound to be safe as a supplement right?

Perhaps, except that if we consider the tiny amount of fenugreek seeds that are in a chutney, or the small amount that is likely to be consumed in a curry - the benefits and potential side effects of fenugreek may be less pronounced than when it is used as an supplement.

Even drinking fenugreek tea made from leaves or using those in cooking, is significantly less potent that something made from the seed

Safety as a galactagogue?
Kellymom states:

Fenugreek is on the U.S. Food and Drug Administration's GRAS list (Generally Recognized As Safe). As with most medications and herbs, various side effects have been noted; see the side effects and safety information below.

However another site points out:

Fenugreek has not been evaluated by the FDA for safety, effectiveness, or purity. Additionally, there are no regulated manufacturing standards in place for these compounds. There have been instances where herbal/health supplements have been sold which were contaminated with toxic metals or other drugs.

This makes sense - if it's a herb/spice regularly used in cooking, it's comparable to say turmeric in that it's a regularly consumed food and thus likely to be generally regarded as safe.  Does that therefore mean supplementing with larger amounts of turmeric would have no side effects?

Dosage
The widely accepted daily dose for milk production is 3.5 - 7.3 grams capsule wise (3 x 3 capsules), or 3 teaspoons of seeds.

Some websites state to buy Fenugreek from a specialised herbalist as the quality is better than chain store brands - but if nothing is tested or regulated, how does one begin to compare?

Smaller doses, such as those provided with the supplement (typically 1 - 2.5 g per day) have not been found to be effective at increasing milk supply.

Risks?

As mentioned above in the kellymom quote - various side effects have been noted.

Drugs.com states:

"Do not take fenugreek without first talking to your doctor if you have a bleeding or blood clotting disorder or diabetes, or if you are taking any medicines to prevent or treat a blood clotting disorder or diabetes. Fenugreek has been reported to affect blood clotting and blood sugar levels.

Also, talk to your doctor before taking fenugreek if you have any other medical conditions, if you take medicines or herbal/health supplements other than those previously listed, or if you suffer from allergies (especially to plants). Fenugreek may not be recommended in some situations.Do not take fenugreek supplements without first talking to your doctor if you are pregnant or planning a pregnancy. It is not known whether fenugreek will harm an unborn baby. The amount of fenugreek customarily used in foods is not reported to be problematic. Do not take fenugreek without first talking to your doctor if you are breast-feeding a baby."

Blood Clotting: According to the Memorial Sloan-Kettering Cancer Center (MSKCC), fenugreek may increase the effectiveness of substances with blood-thinning properties. These substances include warfarin, heparin, ticlopidine and other platelet inhibitors and non-steroidal anti-inflammatory drugs such as aspirin and ibuprofen.

Diabetes & Hypoglycemia: A couple of studies have demonstrated fenugreek can reduce blood glucose levels, increasing the risks of hypoglycemia in those susceptible.

Uterine Contractions: Pregnant mothers who notice a drop in supply may reach for the fenugreek - yet nearly every site discussing supplementing highlights it can cause uterine contractions and should not be used when pregnant (indeed fenugreek has been used traditionally to stimulate labour)

Asthma:  Some mothers with asthma have reported fenugreek seeds aggravated their condition.  In contrast others recommend as something to reduce asthma symptoms.

Allergy: Numbness, facial swelling, breathing difficulty and fainting are likely a sign of an allergic reaction. Fenugreek is from the same family as peanuts and chickpeas - and therefore is more likely to provoke a reaction if you are allergic to these.

Iron absorption:  Several sties exploring fenugreek safety state it can interfere with iron absorption so should be avoided by those who are anaemic; a quick hunt online didn't turn up any evidence 

Thyroid issues:  Several sites exploring fenugreek safety, state it can alter balances of various forms of thyroid hormones and thus should be avoided in mothers with thyroid issues.  Again a hunt suggests others have found fenugreek helped with thyroid issues, it seems it all really depends on what the problem is.  The suggestion is fenugreek may curb the conversion of T4, the inactive thyroid hormone, to T3 the active form of thyroid hormone the body uses (1). Some people already have trouble converting T4 to T3 in the body and therefore the addition of fenugreek to these people's diet might make their symptoms of hypothyroid disease much worse (and reduce milk production)

One user on Babycentre said:

"I was just told recently to stop taking fenugreek. I was told by an herbalist that fenugreek can counteract your thyroid condition and even make your symptoms worse. Funny because the day earlier I was in the Dr's office telling him I thought my Thyroid medication needed to be adjusted because I was feeling all the symptoms from before I had it removed. I take Levixyl and since I stopped fenugreek about a week ago, I am feeling better and in a better mood. My supply is up almost an ounce a day which is phenomenal for me."

Potassium: Fenugreek may lower potassium blood levels, it may therefore cause hypokalemia when used in combination with some diuretics, laxatives, mineralocorticoids, or other hypokalemic agents (2)(3)

Some other side effects may occur such as headaches, dizziness, diarrhoea and wind when fenugreek is used at recommended doses.

One mum online felt compelled to let others know in a post entitled The Risks Of Fenugreek, it reads: 

"Not only did it not boost the supply, but I found that it was affecting me and our 3 month old baby. I was having stomach cramps so bad I could barely walk ( not period pain, but actual stomach), I was thirsty all the time and having tension headaches. Our baby also suffered terrible stomach cramps and was generally restless. 

The fact sites my partner looked at confirmed that fenugreek was indeed the cause of our problems. I have now stopped taking it and things are starting to go back to normal.

As a parent wanting the best for your child, you should have more of the facts and I sincerely hope these give you more. As a parenting wanting the best for my child, I did what I thought was something helpful and instead it was a nightmare."

Dr Thomas Hale - often considered a Guru regarding breastfeeding and medications states:

"The transfer of fenugreek into milk is unknown, but untoward effects have not been reported." Hale classifies it in Lactation Risk Category L3 (moderately safe).

Even further food for thought is that Dr Hale rates Domperidone (Motilium) the pharma drug of choice for milk production as  L1 (safest)

But does it work?

One study from February 2011 examined 66 mothers in the early postpartum period found Maximum weight loss was significantly lower in infants whose mothers consumed Fenugreek tea compared to both the placebo and control groups (p < 0.05). Infants in group 1 regained their birth weight earlier than those in control and placebo groups (p < 0.05). The mean measured breast milk volume of the mothers who received galactagogue tea was significantly higher than the placebo and control groups (p < 0.05). (4)

In another small study examining milk production in exclusively breast-pumping women. Ten women kept diaries of their breast milk production for two weeks. The first week established baseline milk production. During the second week three capsules of fenugreek seed were taken three times daily. This observational study used each patient as her own control in comparing breast milk pro-duction with and without the fenugreek. Average daily pump volumes for week 1 and week 2 were compared; the average daily milk volume for week 1 was 207 ml compared to 464 for week 2. This increase was statistically significant (P=0.004). (5)

The upshot

Does this mean we should all throw out the fenugreek and look to other galactagogues?  Absolutely not!   But we do need to recognise that just because something is natural, this does not make it risk free.

When discussing supplements to help increase milk supply with mothers, we should like all other areas of support provide all the information so the mum can make an informed choice.  Simply telling a mum to take fenugreek without making her aware of any potential link with blood sugars or possible interaction with other medication she may be taking/other conditions she may have is I think irresponsible.  A diabetic mum absolutely may decide to explore fenugreek as something that can help with blood sugars as well as supply, but she needs to know that it has the potential to impact on her sugars so she can monitor/adjust insulin as required.  If a mum is aware of potential side effects, she can identify them if they arise and choose to cease using the supplement - if not as we observe above, it can be upsetting to experience.

With items such as cookies or tea, I've noticed contraindications and/or drug interactions are rarely noted.  Nor do some state what dose of each herb or spice is within the product - therefore how can mum ensure she takes the right amount?  It's one thing selling a tea or biscuit as tasty, but if you're going to claim it has milk inducing properties then you surely need to tell women how much to consume? ie minimum and maximum amounts for results?  As discussed above below the recommended dose has been shown to have little impact on supply, too much could increase the risk of unwanted  side effects.

Associated reading: http://www.intelihealth.com/IH/ihtIH/WSIHW000/8513/31402/347265.html

1. doi:10.1016/j.physletb.2003.10.071
2. Lipids 1991;26:191-197.
3. East Mediterr Health J 2000;6:83-88.
4. J Altern Complement Med. 2011 Feb;17(2):139-42. Epub 2011 Jan 24.
5. EFFECT OF FENUGREEK ON BREAST MILK VOLUME, Stephanie Swafford, MD and Pamela Berens, MD.  ANNUAL MEETING ABSTRACTS SEPTEMBER 11-13, 2000

Armadillo Reviews

I've decided to add a review section to the blog, where things, places or events that I and readers like (or don't!) can be shared.  I'm sure as parents most of us have our "top items" we couldn't live without, and if anything like me with my first - also an awful lot of tat that was barely used.



It's definitely not a list of "essentials" but more of an I or a reader loves/loathes idea; perhaps you have found a chain store to be consistently positive and welcoming towards breastfeeding, or perhaps you bought a bouncy chair that sucks and want to let others know to avoid!

Rather than just the usual baby stuff, I thought it would be nice to extend to toddler/children age too as I know lots of readers have older ones - did you buy something brilliant or visit somewhere as a family you want to share with others?

At the moment I'm pondering children's birthday parties - I want something a bit different to the usual home/crafty affair, but play place parties and suchlike are definitely not for us.  The market out there is vast from swimming, bowling or karting parties to street dancing, face painting and even cooking!   (I'm going to pretend the dreaded "princess pamper parties" and suchlike don't even exist)  With prices ranging widely and then of course there's the whole party bag - to do or not to do, I get the feeling I should have started planning months ago.


AA

Well aren't you the perfect parent!!

This it seems is the internet's answer to any discussion that cannot be answered with logic - and it's popularity ever increasing.  But is there a darker side?

Here's how it goes (these are real comments from various places on the web):

"I don't agree with Cry It Out methods, I've seen evidence suggesting it can be harmful and prefer more gentle techniques".

"Well aren't you just the perfect parent!!!!"

"I think smacking children is just wrong, how can "no hitting", followed by a hit teach anything?

"It's great you are such a perfect parent and  don't ever lose your temper and smack"

"I try to be responsive to my child - babywear, breastfeed, co-sleep"

"Groan - another one from the perfect parenting brigade."

In none of the above statements is anyone implying or stating they are the perfect- they are sharing their opinion/experiences on a topic; but it seems the "perfect parent" card is one to be played when there is no logical response, or when emotional response trumps the rational brain.

Just like the marketing behind formula, pushing things we didn't do but know to be better as "perfect", allow  other options to sit as "ok".  The alternative is surely admitting we didn't make the best choice or worse considering something may (however inadvertently) potentially caused harm - for many the former is far easier.

The emotional response may not even be logic based - it could be it simply evokes a feeling of inadequacy, guilt or perceived failure.

But does this have deeper, darker roots?

In Jan 2011, A Mumsnet survey revealed that most parents feel unduly pressured to comply with the ‘model of perfect parenting’ as a result of reading Mumsnet:

‘Modern parents face an increasing number of stress-inducing activities on Mumsnet,’ explained Mumsnet spokesman Susan Thurrock. ‘These include reading about only using organic ingredients, browsing articles about the correct classical music for your child to fall asleep to, or contributing to forums about how to park far enough away from school to make it look like you’ve walked. While good Mumsnet users will be able to achieve all this and more without breaking sweat, the bad parents will struggle.’

I thought the last bit a rather odd statement, but on the whole I'm not sure it's that it's Mumsnet per se, but more that the internet generally provides parents with information they never had access to before.  Pre WWW generation you may buy a book or chat to friends - but mothers didn't often access research studies and discuss outcomes, if the health visitor, midwife or nurse said it - it was assumed true.  The thing about being a parent is the more that the more we know, the worse we can feel if we think we missed the mark, OR if there is suggestion we have.  Even if we do a hundred other things that are fantastic, the however many things we don't do can weigh heavier - even more so if someone didn't have or felt they had no choice in something they did, perhaps due to a lack of support with alternatives.

"Desperation decisions" as I call them, typically envoke the strongest feelings later compared to "informed decisions" - and when people feel vulnerable it makes for tension and our old friend "guilt".

Child development expert and author of Self-esteem for Girls: 100 Tips for Raising Happy and Confident Children Elizabeth Hartley-Brewer agrees.

‘The wider context is the huge pressure on parents to be perfect,’ she says. ‘Mothers who have been successful in their previous lives want to be successful in child-rearing too. They decide what camp they belong to – be it Gina Ford or the Baby Whisperer, the stay-at-home camp or the working mums – and gather on the dividing lines. If you feel insecure and vulnerable, you present a greater degree of certainty to hide it. You have to be right, and show no cracks. From the outside, it can seem a lot like bullying.’

The media, marketing companies and generally those out to make a buck (or sell one ;)) leap on this, just like the formula companies do - and from "Perfect Parenting" stems "Mummy Wars".  Dividing parents makes consumers less powerful and vendors more so - if everyone could discuss, chat and share ideas openly, imagine the potential impact on a brand or product should the masses get a whiff of something amiss, or discussion and support about better alternatives?

PHD in parenting writes brilliantly on the topic here, well worth a read.  It says:

"The perfect parent is a myth. That person does not exist. We all make choices as parents, some free choices and some forced choices. Sometimes we are able to do what is best for our children and sometimes we are not"

Aint that the truth. We have parents anxious they are not making the grade of "perfect", yet just like an airbrushed magazine cover - it's chasing the impossible, a fantasy, it doesn't exist.  We have parents calling each other "perfect" as an insult, apparently involved in some mummy war!  Does that mean we should all stop trying to do our best, educating ourselves, learning and changing the way we do things if we decide that's a better option, stop actively seeking help if we need it?  Absolutely not.  But we do need to realise nobody gets it right all the time, and you know, that's what makes us human.

Advice VERSUS Information & Support

Many times over the years have I had my knickers in a knot over advice versus information and support. It was the great late Pam Lacey, chair of the Association of Breastfeeding Mothers that first really opened my eyes to this concept - and it's one I really wish more breastfeeding supporters would recognise..

So if you're a breastfeeding counsellor, peer supporter or anyone who works with mothers as a lactation worker - please read on!

Advice definition:

"Advice is a form of relating personal opinions, belief systems, personal values and recommendations about certain situations relayed in some context to another person, group or party often offered as a guide to action and/or conduct. ".

and

"Recommendations concerning future action, typically given by someone regarded as knowledgeable or authoritative.

We see advice in many forms: "What I would do if I were you", "you need to", "you must", "you should", right through to a blunt "do X".

The role of a breastfeeding counsellor is not to convey personal opinion or beliefs or to tell mothers what they should do; it is to support the mother and help her explore her options, to help her unpick any confusion she has surrounding a problem and empower her to reach a resolution she is happy with (regardless of whether this sits with your individual beliefs - this isn't your journey).

Good reasons not to give advice:

• To give advice assumes superiority, it presumes you know better than the person asking the question, it also makes you responsible for the outcome. If you give someone advice and they follow it - what if it doesn't work or worse still has a negative impact?

Here's an example of one I see regularly.
"My baby's poop is green, do I need to worry? What should I do?". 

Example of a typical "advice" giving reply: "This is caused by too much foremilk, you should start single side feeding - one breast per feed".

We know there are actually various reasons for green stools, one of which can be insufficient milk intake.  Limiting the baby to one breast could potentially create a more serious problem, particularly if the baby is very young.

And another 

"My baby is colicky and refluxy, won't settle, what should I do?"

Example of a typical "advice" giving reply: "You need to cut out all dairy ASAP".

We know there are actually numerous reasons for colic, one of which is dairy sensitivity - but what if that isn't the problem in this case and so doesn't improve or resolve things?  What if just being told to cut dairy without discussion, exploration or explanation sounds so drastic to the mum asking that she decides to formula feed instead, worried her milk is causing the problem?

• It doesn't empower anyone.  Often mums have already had numerous people give advice - how do they pick who to listen to?  If a counsellor gives advice and then a paediatrician gives conflicting advice, who would you listen to as a vulnerable new mum?  How do they tell good advice from bad?

• Giving advice can leave you open to mistakes.  A mum starts telling you about a situation, you think you have all the information, so you tell her she should do "X".  After hearing your suggestion the mum adds no she doesn't think that would work because of "Y" - a new bit of information the mum hadn't shared before.  Oh you say, then in that case I would do "Z".  The mums confidence is now faltering in you.....

• Longer term advice doesn't help.  What does the mum do next time she has a problem?  She again needs to contact someone for advice!  If the mum had been encouraged to help resolve her own problems with information and support, this empowers her with skills to apply to future issues.

• Advice involves making a "judgement" - offering a non judgemental ear can be very satisfying to the "talker", and help people to feel a weight has been lifted.  People can be reluctant to share what they feel the "listener" won't agree with if judgements are involved.

• Sometimes what people state initially as the problem, actually may not be the real issue - if you give advice rather than encouraging them to unpick their thoughts, this may not come to light.

Alternatives to advice:

Active Listening:
Don't consider problem solving, but listen (really listen) to the big picture. Ask open and closed questions to get all the relevant information so the mum can unload everything in a safe space.

Reflection:
Always clarify clarify and clarify again - "so it sounds like you're saying X, is that right?", sometimes reflection can literally just be echoing back what the person said - when the mum hears it back or summarised, it gives her chance to add things or realise X point isn't as significant as Y and so on.  It can help clarify things for mum too!

Give information:
There is often more than one way of resolving a situation; discussing various options with a mum so she can select what she feels works best for her situation.  Examples include "some mums find X works for them, whilst others prefer " - recommending that a mum with four other children to take her baby to bed and baby moon for a few days may simply not be feasible (particularly if baby is a few weeks old and partner is back at work)

You can still give firm "facts" without giving advice - eg "we know that to maintain a supply if baby isn't at the breast, mums need to express 8-12 times per day".

Outlining WHY often empowers mum to begin to recognise poor advice eg "your breasts know how much milk to make based upon how frequently and how effectively they're drained - therefore if baby isn't feeding directly at the breast, we know mums need to express 8-12 times per day in order to mimic this and protect supply".

Support mum to think things through:

"So you feel X is the biggest issue, what would be the absolute ideal outcome for you?" or "If X was resolved, do you feel that would resolve everything?". "Do you feel X would be practical for you or is Z something you feel more comfortable with", "could X be impacting on Y do you think?"

Mums who receive advice, often leave an encounter feeling more confused than before they arrived - especially if they have previously received conflicting information.  Mums who have received information and support often feel "lighter", as though they have offloaded.  Listening can in itself make a person feel valued.

Believe it or not the most valuable tool you have as a breastfeeding supporter is not your mouth, but your ears.