Rajiv Gandhi University of Health Sciences s14

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFOMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 NAME OF THE MRS.WAGHMARE ANITA CANDIDATE AND NARSING ADDRESS NAVANEETHAM COLLEGE

OF NURSING

BANGALORE

NAVANEETHAM COLLEGE OF NURSING 2 NAME OF THE INSTITUTION NO;132/1, 5th CROSS,

HORAMAVU

BANASWADI , BANGALORE M.SC.NURSING 1 YEAR

3 COURSE OF STUDY AND OBSTETRICS & SUBJECT GYNAECOLOGICAL NURSING

1 4 DATE OF ADMISSION 23.06.2011 TO THE COURSE

5 TITLE OF THE TOPIC “A STUDY TO ASSESS THE EFFECTIVENESS OF FENUGREEK ON MILK PRODUCTION AMONG POSTNATAL MOTHERS IN SELECTED MATERNITY HOSPITALS AT BANGALORE”

2 BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“The nature has designed the provision that infants to fed upon their mother’s milk. They find their food and mother at the same time. It is complete nourishment of them both for their body and soul”. -Rabindranath Tagore After meeting the fundamental needs for establishing breathing and maintenance of body temperature, the subsequent efforts in the care of the newborn babies should be directed towards the provision of adequate nutrition and prevention of infections. Breast milk is an opaque white liquid produced by the mammary glands of the female. It provides the primary sources of nutrition for newborn before they are able to digest other types of food. The early lactation milk is colostrums, and carries the mother’s antibodies to the baby. It can reduce the risk of many diseases in the baby.

For a preterm or low birth weight baby, mother’s breast may be too full or firm to suckle or suckling reflex may not be well developed. In order to encourage and promote exclusive breast feeding to enhance child survival, the Baby Friendly Hospital Initiative (BFHI) was launched jointly by WHO and UNICEF in March 1992. Ten steps are recognized as minimum global criteria for attaining the status of Baby Friendly Hospital. Among them step- 5-shows mother’s how to breast feed and how to maintain lactation, even if they are separated from their infants- the mothers should be taught the art of breast feeding. When the baby is small or sick, they should be taught the correct techniques of expressing the breast milk manually or with the breast pump to maintain adequate lactation.

3 A substance from herb fenugreek prescription medication, etc. that increases milk supply is called a galactagogue.

Medicinally, this herb has phytoestrogens and is famous as a breast milk stimulant in helping mothers lactate. It is considered a galactagogue in that it helps increase lactating women's milk supplies. It is also said to cause breast enlargement. Just like anything, it needs to be used in moderation with the advice of a certified herbalist. Pregnant women do not need to consume Fenugreek since it may bring premature labor, so be aware.The newborn infant also starts to adapt to life outside the womb and its health during this time will be monitored. Focus of postnatal care is to make sure that the new mother is healthy and capable of taking care of the baby and knows how to breastfeed correctly and adjust to a new life with her baby

6.1 NEED FOR THE STUDY

Depending upon the gestational maturity and vigor of the child, there may be difficulties in self feeding. The baby may not be able to suck or there may be incordination between sucking and swallowing. Babies with problems like, cleft lip or palate, or oromotor dysfunction are also unable to suck effectively.1 The preterm baby is also known as the premature infant is the most common admission to Neonatal Intensive Care Unit (NICU). Preterm milk of a mother who delivers prematurely contains more calories, higher concentration of fat, protein and sodium which are needed by her preterm baby.

4 A study was done to demonstrate the importance and benefits of breast feeding. The study involved 773 premature babies who were born extremely underweight. At an age of 30 months, an intelligent test was conducted on all babies. The study concluded that the average mental development in those who were fed with their mother’s milk was more advanced than those fed with infant formula.

Based on WHO source, 2.2 million deaths that occurred among under-fives in India in 2005: More than one-third 35% were due to severe infections including diarrhea, pneumonia and neonatal tetanus ;Another 60% were due to preterm births 31%, birth asphyxia 23% , and congenital anomalies 6% .4 According to UNICEF, a study was done to estimate the problems related to low birth weight incidence, 2007, about 60% of newborn in developing countries are not weighed; South Asia, has the highest incidence of low birth weight babies figuring is almost 75%.5 According to child mortality data base, 2007, 9.2 million children born alive worldwide die before 5years of age. Malnutrition contributes to over a third of these deaths.6 According to CIA World Fact book of May 16 2008- total Infant mortality rate is 32.31 deaths/ 1000 live births.

Based on an article addressing the major causes of newborn death, preterm birth complications cause 27% of newborn deaths and between 60% and 90% of newborn deaths occur in low birth weight babies, most of whom are preterm, and could be saved with simple and better care. A majority of preterm babies can be saved by providing extra care and attention to feeding, warmth, hygiene and prompt identification of illness.

5 These things can cause or contribute to a low milk supply:

Supplementing. Nursing is a supply & demand process. Milk is produced as your baby nurses, and the amount that she nurses lets your body know how much milk is required. Every bottle (of formula, juice or water) that your baby gets means that your body gets the signal to produce that much less milk.

Nipple confusion. A bottle requires a different type of sucking than nursing, and it is easier for your baby to extract milk from a bottle. As a result, giving a bottle can either cause your baby to have problems sucking properly at the breast, or can result in baby preferring the constant faster flow of the bottle.

Pacifiers. Pacifiers can cause nipple confusion. They can also significantly reduce the amount of time your baby spends at the breast, which may cause your milk supply to drop.

Nipple shields can lead to nipple confusion. They can also reduce the stimulation to your nipple or interfere with milk transfer, which can interfere with the supply-demand cycle.

Scheduled feedings interfere with the supply & demand cycle of milk production and can lead to a reduced supply, sometimes several months later rather than immediately. Nurse your baby whenever she is hungry.

Sleepy baby. For the first few weeks, some babies are very sleepy and only demand to nurse infrequently and for short periods. Until baby

6 wakes up and begins to demand regular nursing, nurse baby at least every two hours during the day and at least every 4 hours at night to establish your milk supply.

Cutting short the length of nursings. Stopping a feeding before your baby ends the feeding herself can interfere with the supply-demand cycle. Also, your milk increases in fat content later into a feeding, which helps baby gain weight and last longer between feedings.

Offering only one breast per feeding. This is fine if your milk supply is well-established and your baby is gaining weight well. If you're trying to increase your milk supply, let baby finish the first side, then offer the second side.

Health or anatomical problems with baby can prevent baby from removing milk adequately from the breast, thus decreasing milk supply.

Fenugreek seed has been used to support healthy milk production since biblical times. The benefits of fenugreek in breastfeeding are believed to stem from diosgenin, a compound that is similar to the female hormone estrogen. More specifically, diosgenin has been shown experimentally to increase milk flow. As such, the use of fenugreek to encourage lactation could offer help to women with insufficient supply. However, there needs to be more scientific evidence of the herb's effectiveness in increasing milk production.

7 In 1945, an Egyptian researcher reported that fenugreek is a potent stimulator of breastmilk production. In fact, its use was associated with increases in milk production of as much as 900%. We have been recommending fenugreek for six years whenever a mother's milk production is determined to be low. To date, we have worked with at least 1200 women who have taken the herb. Many of these mothers began by changing the frequency and duration of breastfeeding: In some cases the use of a fully automatic breast pump was necessary when it was determined that the infant did not sufficiently drain the breast. A significant number of mothers who took the herb, however, did not need other interventions. These included mothers who were exclusively pumping for non-nursing infants and mothers who were feeding often whose babies sufficiently drained the breast. Nearly all of the mothers who take fenugreek report an increase in milk production, generally within 24 to 72 hours after starting to take the herb. Most mothers have found that the herb can be discontinued once milk production is stimulated to an appropriate level. Adequate production is usually maintained as long as sufficient breast stimulation and emptying continues. To date, we have not observed or heard of any side effects in the infants whose mothers have taken fenugreek. So the investigator has found that fenugreek enhances milk production and its important to do a research on it among postnatal mothers.

8 6.2 REVIEW OF LITERATURE

A review of literature related research and theory on a topic has become a standard and virtually essential activity of scientific research projects “Literature review is a critical summary of research on a topic of interest, often prepared to put a research problem in contact or as the basis for an implementation project.” Review of literature was undertaken to gain in depth knowledge on various aspects of the problem under study.

Review of literature for the present study has been recognized under the following headings

SECTION A: Literature related to breast feeding

SECTION B: Literature related to effect of fenugreek on breast milk

SECTION C: Literature related to effect of fenugreek on production of breast milk in postnatal mothers.

SECTION A: Literature related to breast feeding.

A study was done to describe maternal, neonatal, and outside influences associated with the intention, initiation, and duration of breastfeeding for women whose newborns were admitted to the neonatal intensive care unit. One hundred mothers were interviewed. Most mothers about 67% intended to breast-feed exclusively and this was significantly related to maternal characteristics such as age, education, parity, smoking and marital

9 status, pre-breast-feeding experience, and the influences of the neonate's father and prenatal education. 78 mothers initiated pumping. Initiation was significantly related to maternal education, smoking, parity, previous breastfeeding experience, the neonate's physician, the neonate's father, and postpartum breast-feeding education. 54 mothers were followed up by telephone after discharge until weaning. 30% were exclusively breastfeeding at 2 weeks after discharge, and 15% were breast-feeding at 1 year. The study concluded that the duration of breast-feeding was significantly associated with education, marital status, ethnicity, and income, assistance from nurses and lactation consultants, and feeding method along with milk type and milk volume at discharge. Increased family support, timely breastfeeding information, and a supportive neonatal intensive care unit environment are needed for women to succeed in breast-feeding their hospitalized newborns.

A study revealed that about 2.1 million Indian children under 5 years of age die each year. In spite of reductions in child mortality rate over the past two decades, the rate remains high at 87 per 1000 live births. The main causes are diarrhea, pneumonia, and for deaths among the neonates asphyxia, pre-term delivery, sepsis and tetanus. The major underlying cause of death is undernutrition. Child survival interventions of proven impact, feasible for use at high coverage in India were identified, and their effect on child mortality was calculated if high coverage were to be achieved. Exclusive breastfeeding, oral rehydration therapy, and adequate complementary feeding were among the most effective interventions. No cause specific mortality data were available from individual Indian states. Nevertheless, the range of child mortality, as well as the proportion of neo-

10 natal deaths, occurring across the states, suggests that at state level 50-70% of deaths can be prevented. The results show that the targets set in the millennium development goals as well as in the Tenth Five Year plan can be reached.

A study based on retrospective records analysis to determine the incidence of breast-feeding in very preterm babies while in neonatal intensive care of all 151 babies with gestational age less than 35 weeks admitted to the Neonatal Intensive Care Unit (NICU) of a major teaching hospital was performed. On discharge 64% of babies were having some breast milk :45% having breast milk alone, 19% both breast milk and formula , and 38% some breast-feeding :17% being solely breast-fed, the other 21% combining breast-feeding with either bottle-feeding or an IntraGastric Tube [IGT]. Breast milk was the first milk for 41% of babies, with 83% having breast milk at some stage. Increasing gestational age was associated with a decreased likelihood of first milk being breast milk, 73% of those less than 29 weeks compared to 21% of those aged 33-34 weeks, P < 0.001, but with increased rates of breast-feeding 23 compared to 59%, P = 0.01 and breast milk consumption 42 compared to 73%, P = 0.04. The study concluded that Breast-feeding rates in NICU are well below those found on discharge for full term babies. Both maternal and staff-related factors contribute to this. More and better education of mothers, and nurses as well as changes to some unit practices could increase these rates.

11 SECTION B: Literature related to effect of fenugreek on breast milk.

Turkyılmaz C et al.,(2011)a study was conducted to evaluate whether consumption of maternal herbal tea containing fenugreek had any effects on breast milk production and infants' weight gain pattern in the early postnatal period. Sixty-six (66) mother-infant pairs were randomly assigned to 3 groups. Group 1 (n = 22) consisted of mothers who were receiving herbal tea containing fenugreek every day. Group 2 (n = 22) and group 3 (n = 22) were assigned as placebo and controls, respectively. Birth weight, loss of birth weight, time of regain of birth weight, amount of breast milk assessed on the third day after delivery were determined. Maximum weight loss was significantly lower in infants in group 1 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).The study was concluded that Maternal galactagogue herbal tea supplementation which is the extract of fenugreek seems to be useful for enhancing breast milk production and facilitating infant birth weight regain in early postnatal days.

Gabay M.P.(2004)conducted a study to show that galactogogues a product of fenugreek aid in initiating and maintaining adequate milk production. Most exert their pharmacologic effects through

12 interactions with dopamine receptors, resulting in increased prolactin levels and thereby augmenting milk supply. Metoclopramide remains the galactogogue of choice due to its documented record of efficacy and safety in women and infants. Domperidone crosses the blood brain barrier and into the breast milk to a lesser extent than metoclopramide, decreasing the risk of toxicity to both mother and infant possibly making it an attractive alternative. Traditional antipsychotics, sulpiride and chlorpromazine, have been evaluated, but adverse events limit their use. Human growth hormone, thyrotrophin-releasing hormone, and oxytocin have also been studied. Finally, a natural product, fenugreek, has been purported to be effective in anecdotal reports. Use of this agent may be warranted after considering risks versus benefits.

Jonnalagadda S.S,et al(1994)conducted a cross sectional study to that In vitro iron availability was determined from a standard cereal meal (C) with and without the addition of protein isolates from breast milk (BP), groundnut milk (GP) and soybean milk (SP). A second set of studies were done to investigate the potentially available iron from fenugreek leaves per se and the effect of their addition on the available iron from the cereal meal. The potentially available iron from the meal increased from 4.91% to 6.73% on the addition of BP. The next best enhancer was GP (4.91% to 6.17%). Although the addition of SP increased the total iron content of the cereal meal significantly, the percent available iron decreased compared to the other milk proteins. The addition of fenugreek leaves (100 g/meal) to the meal increased the total iron content of the meal significantly (3.24 mg to

13 9.12 mg) (p < .001), however, the available iron was observed to decrease (4.91% vs. 4.34%).

The Academy of Breastfeeding Medicine (2011) conducted a study for the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. The conclusions of the result are not intended to be all-inclusive, but to provide a basic framework for physician education regarding breastfeeding.

SECTION C: Literature related to effect of fenugreek on production of breast milk in postnatal mothers.

Zuppa A.A, et al(2010).a study was conducted to analyze to the literature relating to the principal drugs used as galactogogues (metoclopramide, domperidone, chlorpromazine, sulpiride, oxytocin, growth hormone, thyrotrophin releasing hormone, medroxyprogesterone).Sample were selected from maternity clinic,the samples were the breast feeding mothers who were complaining of decreasd milk production. . The result of the study should be one of the most frequent indications for the use of galactogogues is the diminution of milk production in mothers using indirect lactation, particularly in the case of preterm birth. Have been also analyzed galactogogues based on herbs and other natural substances (fenugreek, galega and milk thistle). The researcher evaluated their mechanism of action, transfer to maternal milk, effectiveness and

14 potential side effects for mother and infant, suggested doses for galactogogic effect, and recommendation for breastfeeding.

Jackson PC.(2010)conducted a study to find any complementary and alternative therapies have been proposed to assist with lactation in NICU mothers. These methods for increasing breast milk supply include herbal galactagogues, kangaroo mothering, and relaxation therapies.A review of the literature was performed using PubMed and CINAHL databases. Twenty-four sources were chosen for inclusion in this article’s a result search terms included the following: galactagogues, breastfeeding, kangaroo care, and lactation, among others. The conclusion of the study was science of alternative therapies in the management of inadequate breast milk supply is achieved by increasing the production of milk which makes the infant to consume without strain and the best complementary and alternative therapies was galactagogues from fenugreek.

6.3 STATEMENT OF THE PROBLEM

“ A study to assess the effectiveness of fenugreek on milk production in postnatal mothers in selected maternity hospital at Bangalore”

6.4 OBJECTIVES OF THE STUDY:

1) To assess the existing milk production.

2) To assess the effect of fenugreek in milk production.

3) To impart knowledge regarding effectiveness of fenugreek on milk production in postnatal mothers

15 6.5 RESEARCH HYPOTHESIS:

Hypothesis 1:There is significant effect of fenugreek on milk production.

Hypothesis 2: There is significant association with selected demographic variables.

Hypothesis 3 : There is significant increase in level of knowledge of postnatal mothers regarding use of fenugreek in milk production.

6.6 RESEARCH VARIABLES

INDEPENDENT VARIABLES: Use of fenugreek in milk production.

DEPENDENT VARIABLES : Knowledge of postnatal mothers.

6.7 OPERATIONAL DEFINITIONS

Assess:To estimate or judge the value, character, etc., of; evaluate: to assess the knowledge of women about reproductive tract diseases.

Effectiveness: It refers to the outcome of increasing the knowledge of postnatal mothers regarding significant of use of fenugreek in milk production.

Fenugreek (also known as Greek Hay and Fenigreek), is an herb that is commonly found growing in the Mediterranean region of the world. While the seeds and leaves are primarily used as a culinary spice, it is also used to treat a variety of health problems in Egypt, Greece, Italy, and South Asia.

Postnatal period: The postnatal period begins immediately after birth and extends for about six weeks. It is a time when the mother's body, including

16 hormone levels and uterus size, returns to how it was before pregnancy and breastfeed correctly and adjust to a new life with her baby 6.7 ASSUMPTIONS:

1. Women will be having some knowledge related use of fenugreek in milk production.

2. Postnatal mothers will have good production of milk after the use of fenugreek.

6.8 DELIMITATIONS:

1. This study is limited to breast feeding postnatal mothers.

2. This study is limited only postnatal mothers with less milk production.

7. MATERIALS AND METHODS

7.1 SOURCES OF DATA : The data will be collected from the postnatal mothers in postnatal ward of selected maternity Hospital in Bangalore. .

7.2 METHOD OF DATA COLLECTION:

Research design : Research design adopted for the study is experimental design.

Research settings : The study will be conducted in postnatal ward of selected maternity Hospital in Bangalore. .

Population : postnatal mothers with less milk production.

17 Sample size : Sample size of the present study consists of 50 postnatal mothers

Sampling technique: The convenient sampling technique will be used to collect data from the available group falling under inclusive criteria.

7.2.9 SAMPLING CRITERIA

INCLUSION CRITERIA:

1. Women who are lactating and have less milk production.

2. Women who are available in the postnatal ward.

3. Women who are willing to participate in the study.

4. Women available at the time of data collection.

EXCLUSION CRITERIA

1. Pregnant women

2. Not interested to participate in the study

3. Not available at the time of data collection.

4. Have adequate milk supply.

7.2.10 TOOLS FOR DATA COLLECTION

PART A: Consists of demographic variables such as age, sex, socio- economic status, marital status, obstetrical history of postnatal mothers.

18 PART B: Administration of 6 grams of fenugreek and evaluating the milk production.

METHOD OF DATA COLLECTION

A prior permission will be obtained from selected maternity Hospital in Bangalore for conducting the study.

The study will be conducted by giving 6 grams of fenugreek early in the morning.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS ?

Yes, because the researcher is assessing the effectiveness of fenugreek in postnatal mothers by giving fenugreek early in the morning

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED ?

Permission will be obtained from the institutional ethical research committee of Navaneetham College of nursing, Bangalore.

Permission will be obtained from authorities of selected maternity Hospital in Bangalore.

Informed consent will be obtained from women, who are willing to participate in the study.

Confidentiality and anonymity of the subject will be maintained.

19 6. LIST OF REFERENCES:

1. Castleman M. The Healing Herbs. Emmaus, Pa:RodalePress;1991.

2. Fleiss P. Herbal remedies for the breastteeding mother. Molhering. 1988;Summer : 68-71

3. Hoffmann D. Therapeutic Herbalisrn: A Correspondence Course in Phytotherapy {self-published).

4. Jensen R. Fenugreek-overlooked but not forgotten. UCLA Lactation Alumni Association Newsletter 1992; 1:2-3.

5. Ody P. The Compiete Medicinal HerbaL NewYork:Dorling Kindersley;1993.

6. Rosengarten F. The Book of Spices. Wynnewood, Pa: Livingston Publishing Co.;1969.

7. Simon J. ,et al. Herbs, An lndexed Bibtiograghy 1971 1980. NewYork:Archon Books; 1984.

8. Thomson W. Herbs That HeaI. New York: Charles Scribner's Sons;1976.

20 9. Willard T. The Wild Rose Scientific Herbal Calgary: Wild Rose College of Natural Healing;1991

10. Hermann M. Herbs and Medicinal Flowers. New York:Galahad Books;1973.

11. Pharmaceutical Information Associates. Feougreek. The Lawrence Review of Natural Products 1981;July.

Turkyılmaz C The effect of galactagogue herbal tea on breast milk production and short-term catch-up of birth weight in the first week of life. 2011 Jan 24 Pp; 450-451.

Zuppa AA Safety and efficacy of galactogogues: substances that induce, maintain and increase breast milk production. 2010;(13) Pp:162-74.

J Hum Lact. Galactogogues: medications that induce lactation. 2002 Aug;18(3)Pp:274-9.

Jonnalagadda SS, Seshadri S. In vitro availability of iron from cereal meal with the addition of protein isolates and fenugreek leaves (Trigonella foenum-graecum). 1994 Feb;45(2)Pp:119-25.

21 1. Ministry of Health and Family Welfare Govt. of India. Activities In North-East Region.NNT, July 2007 ;( 3)28-32.

2. Dutta DC. ‘Textbook of obstetrics’. 5th ed. Calcutta; new central book agency ltd; 2001:212-31.

3. Mondkar Jayashree, Nanavati Ruchi, Fernandez Armida. Exclusive Breastfeeding –an Obstetrician’s Dilemma. The Journal of Obstetrics and Gynecology of India 2008 May /June ;58(3): 208-10.

4. Jensen R. Fenugreek-overlooked but not forgotten. UCLA Lactation Alumni Association Newsletter 1992; 1:2-3. Ody P. The Compiete Medicinal HerbaL NewYork:Dorling Kindersley;1993.

5. Park`s ‘Textbook of Preventive and Social Medicine.’ 16th ed. Jabalpur: Banarsidas bhanot company; 2000:380-81

6. Ministry of Health and Family Welfare Govt. of India. Maternal Health Programme. NNT, Sept 2006 :( 3) 28-32.

7. Lesley Ann Page, Rona Mc Candlish. The new midwife. 2nd ed. Philadelphia: Churchill Livingstone company; 2006:66-67.

22 8. Katharine, A May, Lavrar, Mahimeister. Maternal And Neonatal Nursing. 3rd edition. p. 270-1994.

9. Women’s health Care Topics: http://www.womenshealthcaretopic.com.

10.Myles. ‘Textbook For midwives’.14th edition .London; Churchill Livingstone (2004):(9);Pp217-23.

11.B.T Basavantappa .’Midwifery and Reproductive Health Nursing’. Ist edition.Jaypee brothers; Pp 171,232-54.

12.Polit D.Fet al’Text book of Nursing Research Principles and methods

13.Lipping Cott Publication, Pp: 57.

14.Bobak and Jenson.Maternity and Gynecologic Care. 5th edition. 1993. Pp.118, 120-22.

15. www.google.com

16. www.pubmed.com

17.www.askMedline.com

18.www.elseivierhealth.com

19.Rosengarten F. The Book of Spices. Wynnewood, Pa: Livingston Publishing Co.;1969. Pp78 Simon J. ,et al. Herbs, An lndexed Bibtiograghy 1971 1980. NewYork:Archon Books; 1984.Pp98

23 20.Thomson W. Herbs That HeaI. New York: Charles Scribner's Sons;1976. Pp76-9

21.Willard T. The Wild Rose Scientific Herbal Calgary: Wild Rose College of Natural Healing;1991 Pp54-6

22. Hermann M. Herbs and Medicinal Flowers. New York:Galahad Books;1973. Pp43-6

23.Pharmaceutical Information Associates. Feougreek. The Lawrence Review of Natural Products 1981;July.Pp34-5

24 9. Signature of the Candidates :

10. Remarks of the Guide

11. Name of the Designation Of :

11.1. Guide :

11.2. Signature :

11.3. Co-Guide(if Any) :

11.4. Signature :

11.5. Head of Department :

11.6. Signature :

12.1. Remarks of the Principal :

12.2. Signature :

25 Turkyılmaz C The effect of galactagogue herbal tea on breast milk production and short-term catch-up of birth weight in the first week of life. 2011 Jan 24 Pp; 450-451.

26 Zuppa AA Safety and efficacy of galactogogues: substances that induce, maintain and increase breast milk production. 2010;(13) Pp:162-74.

J Hum Lact. Galactogogues: medications that induce lactation. 2002 Aug;18(3)Pp:274-9.

Jonnalagadda SS, Seshadri S. In vitro availability of iron from cereal meal with the addition of protein isolates and fenugreek leaves (Trigonella foenum-graecum). 1994 Feb;45(2)Pp:119- 25.