FEATURE Herbals and Breastfeeding by FRANK NICE, DPA, CPHP Assistant Director, Clinical Neural Sciences Program , National Institutes of Health, Bethesda, MD RAYMOND J.COGHLAN, PHARM.D. CoMed BRIAN T. BIRMINGHAM, PHARM.D. Pharmacy Practice Resident,York Hospital , Division of WellSpan Health,York, PA Which herbals are safe to take erbal medica- potential side effects to the tions are used to while breastfeeding? Here’s a nursling. Htreat a variety of • The nursing mother ailments. Unfortunately, guide to popular herbs and their should take oral medications consumers often self- immediately following nurs- medicate without consulting potential risk to nurslings. ing, or right before the an appropriate healthcare infant’s longest sleep to professional. This can be an surpass those benefits achieved by avoid nursling exposure to a unwise decision with serious conse- formula feeding. These benefits are drug at its peak plasma level. quences, especially in breastfeeding two-fold, improving the health of • The nursing mother should mothers. both nursling and mother. Nurslings take the lowest dose possible. She Although many drugs, includ- will tend to have a lower incidence should always avoid extra-strength ing herbal medications, do not enter of ear, respiratory, and gastrointesti- or long-acting formulations. the breast milk to any significant nal infections due to antibodies that Combination products present a degree and are often undetectable in are transferred from mother to the special hazard. milk, safety cannot be implied. child through breast milk.2-4 • The nursing mother should Breastfeeding mothers who use Furthermore, breastfeeding also know the use and side effects for all herbals should consult with a physi- decreases the risk of other diseases constituents of a formulation before cian or pharmacist who has such as childhood diabetes (juvenile using it. She should be aware of information concerning the safety of diabetes),5 Crohn’s disease,6 and potential side effects and she should herbal medications. Only after care- lymphomas.7 One of the most impor- be able not only to monitor herself ful consideration should the mother tant benefits of breastfeeding is the for side effects, but also to monitor be started on these medications or enhancement of the emotional bond the nursling for these side effects or breastfeeding withheld. One impor- that develops between the mother unusual changes in behavior.8 tant consideration is that stopping or and the child. Breastfeeding tends to temporarily stopping breastfeeding reduce stress in the infant, gives the GALACTOGOGUES is not always the best answer. infant a sense of security, and Chaste Tree: Chaste tree fruit Presently, the number of post- provides maternal comfort. from the species Agni Casti Fructus partum mothers who are is used as an alcoholic extract tradi- breastfeeding is increasing. COUNSELING NURSING MOTHERS tionally to treat dysmenorrhea by According to the Ross Laboratories If possible, always advise a regulating the menstrual cycle. Mothers’ Survey, there has been a nursing mother to pursue nonphar- Chaste tree fruit is believed to exert a significant increase in the initiation macological therapy to treat her dopaminergic influence, thus inhibit- of breastfeeding and in maintaining symptoms. When this is not an ing prolactin secretion.9 Like nursing at six months of age.1 The option and true medical intervention Bugleweed, Chaste tree fruit has also benefits of breastfeeding greatly is necessary, certain techniques can been used to relieve symptoms of be employed to decrease the risk of mastodynia associated with nursing.

COMMUNICATION SEPTEMBER/OCTOBER 2001 9 Herbals and Breastfeeding

No special cautions are known with concern regarding coumarin deriva- binin, silydianin, and silychristin, regard to Chaste tree fruit. However, tives in fenugreek and state that which supposedly some people taking Chaste tree fruit fenugreek should be avoided have liver-protect- have developed itching and rash.10 If during breastfeeding. As a side ing properties. used during nursing, Chaste tree note, the American Academy of Common side fruit may affect milk production and Pediatrics considers dicoumarol to effects include laxa- subsequently nursing performance. be compatible with breastfeeding.12 tive effects and Furthermore, Chaste tree fruit extract Garlic: Garlic was formerly reported allergic contains a high alcoholic content of believed to cause “colicky” infants reactions. There are approximately 50%–70%. Despite the if the mother ingested it while no known contraindications to its lack of absolute contraindication breastfeeding. Well use. The average daily dose is 12–15 to breastfeeding, Chaste tree fruit known for its cardio- grams which is equivalent to 200–400 should be used with due caution, vascular effects, garlic mg of silibinin. It is administered as observing for any negative influ- was dem-onstrated to an infusion and other galenical ence on nursing performance. enhance nursling formulations.10 Fennel: Fennel has been performance during used historically as a galacto- breastfeeding.12,13 In ANALGESICS gogue (to stimulate milk these reports, an Bugleweed: Also known as production).11 It has also been used equal number of women from the gypsywort or lycopi herba, for gastrointestinal disorders and as garlic group and the lactose-contain- Bugleweed contains hydrocinammic an expectorant. The dose of the oil is ing placebo group reported “colicky” acid, caffiec derivatives, flavonoids, 0.1-0.6 mL which is equivalent to infants. Nursing time was increased and lithospermic acid. Traditionally, 100-600 mg of herb. Side effects in the garlic group; however, this it has been used to counter mild include allergic reactions and increased time did not correlate to thyroid hyperfunction and to relieve dermatitis. There are no known increased volume of milk ingested. mastodynia or tension and pain in contraindications for fennel oil.10 In addition, after repeated serial the breast. Bugleweed is taken by Fenugreek: Fenugreek is used exposure to garlic-flavored milk, mouth as either a freshly pressed internally to stimulate appetite. It nursing time decreased. The dose of juice or a crushed herb. No data exist 10 has also been used as external poul- garlic in the studies was 1.5 g of on its safety in breastfeeding.. tice to control inflammation. garlic per capsule once daily for However if used during breastfeed- Fenugreek has been used fairly three consecutive days.14 ing, both baby and mother should be extensively by lactation consultants Goat’s Rue: Goat’s rue has monitored because in rare instances, to increase milk production in nurs- found some current favor among extended exposure to Bugleweed has ing mothers. It is available in alcohol lactation consultants to stimulate resulted in thyroid enlargement. based liniment formulations, oint- milk production. Historically it has Usual daily doses of Bugleweed are ments, gels, or oils. A bath additive been used as a galactogogue. It 1–2 grams for the tea or 20 mg of the product also exists. The recom- consists of the dried, above-ground extract. mended dose of fenugreek is 6 parts of the herbal family, Fabacae. Comfrey: Comfrey root is a grams if taken orally, or 50 grams Goat’s rue contains galegin, which topical herb applied to bruised areas, mixed in eight ounces of water has a hypoglycemic action similar to sprains, or pulled muscles to relieve applied to the area of inflammation. those of synthetic guanidine deriva- pain. Extracts, pressed juice, or the The major side effect of fenugreek tives.10 One recommended dose is crushed roots of comfrey root are are skin reactions following repeated 1–2 mL of the tincture 2–3x a day. used to prepare poultices for external exposure to the external products. Although there are no known application. The drug contains allan- No known contraindications limit contraindications for the use of toin and varying amounts of the use of fenugreek.10 However, Goat’s rue during breastfeeding, its pyrrolizidine alkaloids and fenugreek contains bitter principles, effectiveness as a human galacto- pyrrolizidine alkaloid derivatives. and if used externally around the gogue has not been documented. Pyrrolizidine is a well-known hepa- nipple area prior to nursing, residual Milk Thistle: Milk thistle has totoxin that has been found to enter 11 drug may alter nursing performance. been used historically to increase the breast milk of lactating rats. Some experts have expressed milk supply.11 The drug contains sili- Comfrey root is an anti-inflamma-

10 COMMUNICATION SEPTEMBER/OCTOBER 2001 Herbals and Breastfeeding tory agent that has antimitotic either a tea or juice. Other galenical drink one to two cups of tea several actions. Ointments are available in preparations (e.g., tinctures, boiled times a day. Recommended doses varying strengths ranging from and strained products) are available. vary by preparation. The average 5%–20%. The German Commission E The usual daily dose of Coltsfoot leaf daily dose is 10–15 grams of drug a recommends that daily doses not tea is 4.5–6 grams not exceeding 10 day, 1.5–3 grams fluid extract, and exceed 100 mg of the pyrrolizidine mg of pyrrolizidine alkaloids and 2.5–7.5 grams tincture. Elder flower alkaloids and pyrrolizidine alkaloid pyrrolizidine alkaloid derivatives. tea acts as a diaphoretic and also derivatives. Furthermore, accompa- Acceptable pyrrolizidine amounts increases bronchial secretions. No nying warnings dissuade against are further reduced to 1 mg in known side effects or contraindica- prolonged use of this agent, recom- instances where such preparations as tions are known. Therefore, use of mending limited use for no more the pressed juice are used. Coltsfoot elder flower tea during nursing is than 4–6 weeks a year..10 Comfrey leaf is contraindicated during both not contraindicated.10 root should be avoided during pregnancy and nursing because of breastfeeding for two reasons: the the potential toxic liver effects and ANTI-ASTHMATIC PREPARATIONS potential of hepatotoxicity secondary its antimitotic action. Its use is Ephedra: Ephedra, commonly to pyrrolizidine and its antimitotic recommended not to exceed 4–6 known as ma huang, is a potent herb properties. weeks total during a year.10 indicated for the alleviation of Echinacea: A very popular asthma-associated bronchoconstric- HEADACHE (MIGRAINE) AGENTS herb commonly used to boost the tion. Ma huang has become famous Feverfew: Derived from the immune system is Echinacea, other- for its purported vitalizing, stimulat- leaves of Tanacetum parthenium, wise known as purple coneflower. ing effects. Ephedra contains the feverfew may decrease the number Echinacea has been used to prevent alkaloids ephedrine and pseu- and severity of migraine attacks. The the common cold, promote wound doephedrine. Available as either a main active component of feverfew healing, and treat uncomplicated comminuted herb or other galenical is thought to be parthenolide, a lower urinary tract infections. No preparations, ephedra acts by indi- sesquiterpene lactone. Feverfew known side effects exist for the inter- rectly inhibiting the preparations are available in capsule nal or external applications of sympathomimetic and central nerv- and tablet form. However, due to the Echinacea. Echinacea does contain a ous system. German Commission multiple unique preparations of this specific form of pyrrolizidine. E-recommended single doses are product, gross differences in dosing, However, this form is considered to 15–30 mg total ephedrine alkaloid in 9 efficacy, and safety may exist. be a nontoxic derivative of adults and 0.5 mg/kg in children. A Specifically, thujone, a compound pyrrolizidine.11 Echinacea is available daily dose of 300 mg should not be found in Tansy preparations, is as a tea, tincture, expressed juice, or exceeded in adults. Correspondingly, neurotoxic. Toxicity studies of capsule. children should not receive more thujone-free preparations of feverfew A daily dose of 900 mg is than 2 mg/kg/day of the ephedrine 10 are not available. Standardization recommended in adults. No known alkaloid. In addition to bronchodila- of these preparations is warranted, contraindications to its use during tion, ephedra also causes and until then, safety in breastfeed- nursing exist other than allergy to vasoconstriction, tachycardia, insom- ing cannot be assured. the plant family Asteracea (sunflow- nia, and motor restlessness. ers). The recommended duration of Contraindications include, but are COUGH, COLD, AND ALLERGY not limited to, anxiety disorders, PRODUCTS treatment with Echinacea should not exceed 8 weeks during any course of hypertension, glaucoma, and thyro- Coltsfoot: Coltsfoot leaf, or treatment due to potential liver toxi- toxicosis. Ephedra preparations may Farfarae folium, is used as an anti- city and tachyphyaxis.15 Patients cause tachyphylaxis and addiction; inflammatory agent during acute with conditions such as tuberculosis, therefore, only short-term use is upper respiratory disturbances. Like 10 HIV infection, or autoimmune recommended. Given the potential Comfrey root, Coltsfoot leaf acts by diseases should not use Echinacea.10 cardiovascular risks as well as the inhibiting mitosis related to inflam- Elder Flower: Elder flower tea, risk of addiction, the use of mation. It also contains the liver otherwise known as sambuci flos, is ephedrine or ma huang is not recom- toxin pyrrolizidine and its related used during episodes of acute upper mended during breastfeeding. toxic derivatives. It is consumed as respiratory infection. Patients should

COMMUNICATION SEPTEMBER/OCTOBER 2001 11 Herbals and Breastfeeding

CONSTIPATION root should be avoided while breast- hydroxyanthracene (calculated as Aloe: Aloe, obtained from the feeding because of their anthranoid sennoside B). Senna leaf and pod are dried latex of the content. available in liquid and tablet form. leaves of Aloe Flaxseed and Psyllium Senna is also available as an herbal barbadensis and other Seed (Blonde): Flaxseed is a tea preparation.10 Herbal medica- Aloe species of its bulk forming laxative containing tions of senna contain anthranoids genus, is used to treat fiber and fatty oils. Collected and should be avoided while nurs- constipation. Its phar- from Linum usitatissimum, the ing. Although there are reports that macologic actions are seeds must be cracked, not deny negative effects on the due to its hydroxyan- ground, to produce a laxative nursling,11 the German Commission thracene derivatives, effect. The recommended dosage E recommends avoiding this herb which increase motil- of flaxseed is one tablespoon of while breastfeeding. ity of the GI tract and cracked seed with five ounces of prevent the colon from becoming water or juice two to three times a INDIGESTION/ULCERS stationary. Aloe is available orally as day. When flaxseed is taken as Chamomile: Chamomile is a powder and aqueous extracts recommended, there are no known derived from fresh or dried flower (powdered or liquid). The recom- side effects.10 Flaxseed is not heads of Matricaria recutita but is mended dose of aloe should be absorbed systemically and therefore found in many herbal teas available based on the hydroxyanthracene poses little threat to the nursling in grocery stores and retail pharma- content of the dosage form. The during breastfeeding. Psyllium seed cies. Chamomile has antispasmodic daily dose is 20–30 mg hydroxyan- (blonde) is also a bulk-forming laxa- as well as anti-inflammatory effects thracene/day calculated as tive that contains seeds of the plant on the GI tract, which are attributed anhydrous aloin. However, the dose Plantago ovata. The dosage of psyl- to the terpenoids (bisabolols), should be reduced, if possible, to the lium seed or other galenical flavonoids and matricin found in the 9 lowest dose required to maintain a preparations is 12–40 grams daily flower heads of chamomile. The bowel movement. Short-term side taken orally with five ounces of recommended daily use of effects usually result in GI tract water or juice. There are no known chamomile tea is 3–4 freshly brewed distress. On a long-term basis, side side effects to psyllium seed cups a day, drunk between meals. effects encountered include elec- (blonde); however, allergic reactions There are no known or reported trolyte imbalance, albuminuria, and have occurred. Caution should be contraindications or side effects to 10 hematuria. Potassium deficiency is of used in insulin-dependent diabetic the use of chamomile. utmost concern because of the poten- patients as this herbal preparation Licorice: Licorice root is used tial to cause cardiovascular may disrupt the absorption of food. in the treatment of peptic/duodenal dysfunction such as arrhythmias.10 A reduction in daily insulin doses ulcers. The active components in Due to aloe’s anthranoid content and may be necessary.10 As with flaxseed, licorice are thought to be glycyrrhizic the side effects caused by anthra- psyllium is not systemically and glycyrrhetinic acids, which noids, it should be avoided while the absorbed. Therefore, psyllium seed account for licorice’s anti-inflamma- mother is breastfeeding. (blonde) can be safely used while tory and anti-allergic effects. The Buckthorn, Cascara Sagrada, breastfeeding. recommended daily dose is 1.5–3 and Rhubarb: Buckthorn, cascara Senna: Senna leaf and pod, grams as Succus liquiritiae to treat sagrada, and rhubarb root have simi- obtained from Cassia senna, contain ulcers and is available in liquid and lar pharmacological actions as aloe, hydroxyanthracene derivatives, solid dosage forms. However, the due their hydroxyanthracene including sennosides, which increase components of licorice root possess content, and therefore have similar motility of the GI tract and prevent mineralocorticoid properties leading side effects. They are available in the colon from becoming stationary. to unwanted and sometimes fatal liquid and solid forms for oral use, Herbal preparations of senna have side effects, including sodium and and dosages are 20–30 mg of hydrox- similar side effects as other hydrox- water retention, hypokalemia, and yanthracene calculated as yanthracene derivative-containing hypertension, which can lead to 10 glycofrangulin A, caacaroside A, and herbal preparations used for consti- heart failure or even cardiac arrest. rhein, respectively.10 Like aloe, buck- pation. The recommended daily dose Due to these effects, licorice should thorn, cascara sagrada, and rhubarb of senna leaf or pod is 20–30 mg not be used while nursing.

12 COMMUNICATION SEPTEMBER/OCTOBER 2001 Herbals and Breastfeeding

NAUSEA AND VOMITING ginger causes any harm to the URINARY TRACT PREPARATIONS PREPARATIONS mother or the nursling. Goldenrod: Goldenrod is Ginger: Ginger root is indi- harvested from various species of cated for the alleviation of symptoms WEIGHT CONTROL/LIPID Solidago and is considered one of of motion sickness or nausea as well LOWERING AGENTS the safest and most effective herbal as dyspepsia. Obtained from the Herbal Phen-Fen: Herbal medications for inflammation of the rhizome of Zingiber phen-fen is merely a combination lower urinary tract. Its action as a officinale, ginger root of two herbs mentioned else- diuretic is attributed to saponins, has activity attrib- where in this article, ephedra and flavonoids, and glycoside leiocarpo- uted to oleoresin (a St. John’s Wort. Herbal phen-fen sides (hydrolyzed to salicylic acid in volatile oil and resin borrows its name from the once the intestinal tract).9 Goldenrod is mixture), and the popular, and lethal, weight-loss available as tea and other botanical sesquiterpene hydro- combination of phentermine and preparations, and a dose of 6–12 carbons, zingiberene fenfluramine. The use of herbal grams daily is recommended. and bisa-bolene. Available as 500 mg phen-fen during nursing is not Goldenrod should be taken with of powdered rhizome capsules, the recommended. copious amounts of water.10 No recommended dose of ginger is two Soy Lecithin: Soy lecithin known side effects or contraindica- capsules once motion sickness or consists of various phospholipids tions have been reported for this nausea begins, then 1–2 capsules extracted from the Merrill family herbal medication. Although data every four hours as needed for plants. Supporters of soy lecithin concerning goldenrod’s transfer into motion sickness or nausea.9 No suggest that it may provide some breast milk is lacking, goldenrod known side effects have been benefit in people with hypercholes- appears to be safe for breastfeeding reported. The German Commission E terolemia when dietary response is mothers. notes that use of ginger during preg- less than optimal. Dosages should be Petasites: Petasites root is an nancy to manage morning sickness is determined by the amount of 3-ns- antispasmodic agent used to treat contraindicated.10 The editor of the phosphatidylcholine contained in the acute spastic, urinary tract pain as, Commission E Monographs notes, preparation. The recommended dose especially pain related to stones. 10 though, that a review of the litera- is generally 3.5 grams daily. There Petasites root contains sesquiter- ture does not justify this caution. It is are no known contraindications to its penes, and also pyrrolizidine stated that there is no evidence that use by breastfeeding mothers. alkaloids which have toxic deriva- tives. The drug is available as an Table 1 ethanol-based extract and other Selected Herbal Products galencial preparations. Usual doses INDICATION CONTRAINDICATED RECOMMENDED ALTERNATIVE of petasites root are equivalent to Galactogogues Chaste Tree*, **, Fennel*, Fenugreek*, Garlic, Goat’s Rue, Milk Thistle 4.5–7 grams of drug but should not Analgesics Comfrey Bugleweed*,** exceed a total of 1 mg of Headache (Migraine) Feverfew pyrrolizidine and its toxic compo- Agents Cough, Cold, and Coltsfoot Echinacea, Elder Flower nents.10 Pyrrolizidine probably enters Allergy Products breast milk and is a known toxin that Anti-Asthmatic Ephedra 11 Preparations causes liver injury. Pyrrolizidine- Gastrointestinal Aloe, Buckthorn, Cascara Sagrada, Flaxseed, Psyllium Seed (Blonde), containing products, such as Agents Licorice, Rhubarb, Senna Chamomile petasites root, are therefore Nausea and Ginger Vomiting contraindicated during nursing. Preparations Uva Ursi: Uva ursi, sometimes Weight Control/Lipid Herbal Phen-Fen Soy Lecithin called bearberry leaves, has been Lowering Agents Urinary Tract Petasites, Uva Ursi Goldenrod used to treat urinary tract infections. Preparations Uva ursi does have an antimicrobial Anti-Anxiety Agents Indian Snakeroot, Kava Kava Passionflower*, St. John’s Wort*, Valerian* effect against some strains of E. coli, Stimulants Angelic Root/Dong Quai, Ginseng Ginkgo biloba* Root, Siberian Ginseng Proteus vulgaris, S. aureus, and P. Sleep Preparations Melatonin aeruginosa. This action is related to a * Monitor nursling for potential side effects component found in Uva ursi called ** May decrease prolactin level

COMMUNICATION SEPTEMBER/OCTOBER 2001 13 Herbals and Breastfeeding aglycone hydroquinone. Aglycone mg of drug (corresponding to 6 mg regard to its use in nursing moth- hydroquinone is released from its of total alkaloid calculated as reser- ers.10 Due to its potential sedating transport form, arbutin, in alkaline pine) is recommended. As a effects on the nursling, breastfeeding urine. The drug is said to have an Rauwolfian alkaloid, Indian infants should be monitored for this inhibiting effect on tyrosinase activ- Snakeroot, like reserpine, can also possibility. ity. Tyrosinase plays an important cause central nervous system depres- St. John’s Wort: Perhaps the role in the formation of melanin from sion due to the breakdown of most well-known herb today is St. DOPA. The effect of this inhibition is norepinephrine. It is therefore John’s Wort, used in the treatment of a decrease in melanogenesis. contraindicated in breastfeeding.10 depression and anxiety. Its active Therefore, duration of treatment Kava Kava: Kava kava is a constituents are obtained from should not exceed seven days or popular herbal medication used for hypericum extracts, which have been more than five times a year with nervous anxiety and restlessness. It shown to alter many of the brain’s either of the following dosage regi- acts by depressing the central nerv- neurochemical pathways, including mens.10 Available in a powder form ous system. The drug consists of inhibition of multiple neurotransmit- for infusions or macerations, there kava pyrones, called kawain, ters.17 Hypericum has a half-life of 25 are two recommended doses. If extracted from the dried rhizomes of hours, and peak plasma levels are taken as a single dose, one would the Piper methysticum plant. Kava reached approximately five hours prepare 3 grams of Uva ursi in 150 kava is available in galenical prepa- after oral ingestion.18 St. John’s Wort mL of water as an infusion or macer- rations as well as in comminuted has no known contraindications, and ation. This dose is equivalent to decoctions. Equivalent doses are the main side effects are photosensi- 100–210 mg of hydroquinone deriva- based on the kava pyrone amount tivity and abdominal symptoms. tives. For a multidose regimen, the and are 60–120 mg daily for adults. Available in capsules, tea, oils, and above directions are followed, and Kava kava is believed to enter breast transdermal patches, the usual dose doses are repeated up to four times a milk and therefore, due to its depres- to treat depression is 0.2–1 mg day. This regimen yields a daily dose sant effects on the central nervous hypericum.10 No known contraindi- of 400–840 mg of hydroquinone system, it is contraindicated in nurs- cation to breastfeeding exists. derivatives. Little is known about the ing mothers. In addition, long-term Valerian: Valerian root is transfer of Uva ursi into breast exposure to Kava kava can cause a perhaps the most effective anxiolytic milk.10 Therefore, its use during temporary, yellow discoloration of in this group.9 Having been used as nursing is not recommended due to skin, hair, and nails.10 a minor tranquilizer and sleep aid possible disruptions in melanogene- Passionflower: Passionflower for over 1,000 years, Valerian root sis. is isolated from the flower of the can either be ingested orally or used climbing vine Passiflora incarnata. as a bath ingredient. The exact active ANTI-ANXIETY AGENTS This herb is most commonly used to constituent remains to be discovered. Indian Snakeroot: Indian treat anxiety and insomnia. The recommended oral dose is 2–3 Snakeroot is used mainly to control Passionflower is often found grams of fresh herb brewed as a tea mild, essential hypertension. Indian combined with other herbal products and taken in divided doses through- Snakeroot has also gained popularity in the same preparations. Thus, it is out the day. Equivalent doses of for the treatment of tension, anxiety, necessary to carefully check all ingre- tincture can also be used. When and psychomotor irritation. It is dients prior to use. Made primarily preparing a valerian root bath, 100 available in powders, galenical of flavonoids, particularly the grams of the herb per tub should be preparations, or as the crushed herb. flavonoid vitexa, and harmala-type used. Side effects or contraindica- This herbal preparation contains alkaloids, Passionflower also tions have not been reported;10 Rauwolfian alkaloids, which are the contains coumarin derivatives. The nonetheless, monitoring the baby for same components contained in early traditional dose is 4–8 grams of drowsiness is advisable. antihypertension agents such as passionflower brewed as a tea and reserpine. Reports of severe mental taken in divided doses throughout STIMULANTS depressive disorders surfaced as the day. Other formulations include Angelica Root/Dong Quai: Rauwolfian alkaloid use increased in capsules. Passionflower has no Angelica root, also known as dong the beginning days of hypertension known side effects or contraindica- quai, has been used in the treatment 16 management. A daily dose of 600 tions. However, no data exist with of female disorders, particularly for

14 COMMUNICATION SEPTEMBER/OCTOBER 2001 Herbals and Breastfeeding the regulation of the menstrual cycle. family, and is known as Siberian sleep cycle, among other physiologic Dong quai contains coumarin and Ginseng. These two different types processes. The normal physiologic coumarin derivatives that are of ginseng each possess very differ- dose is 0.3–0.5 mg a day. Available thought to contribute to its antispas- ent properties and must therefore be manufactured preparations range in modic and vasodilatory effects. Dong discussed separately. dosage forms from 0.5–5 mg. An quai also contains compounds that • Ginseng Root: Ginseng from extended-release formulation is also may stimulate the central nervous the Panax family, or ginseng root, available but should be avoided in system. Angelica root is available as contains steroid-like ginosenosides. breastfeeding. Mothers with autoim- either a pulverized herb or a botani- Claims for this drug are that it mune disorders, diabetes, or cal product. A daily dose of 4.5 g is enhances mental capacity. Also, the depression should avoid using mela- recommended. Certain fura- tonic is advertised to invigorate tonin due to potential adverse nocoumarins present in dong quai during times of fatigue. Daily doses effects.20 No specific information sensitize the skin to light and UV of 1–2 grams of the root are prepared exists on the use of melatonin during radiation.10 Because little is known from cut root or powder. Ginseng breastfeeding. If necessary, a dose of regarding breastfeeding and angelica root may be taken for up to three 1–3 mg appears to be acceptable for root, and with its effect on estrogen months. Little is known about nursing mothers. and photosensitivity, this herb ginseng root and breastfeeding.10 should be avoided during breast- Ginseng may cause estrogenic side CONCLUSION feeding. effects as well as platelet changes.17,18 Both patients and healthcare Ginkgo Biloba: Another well- Until more information is known, professionals must approach herbal known herbal is Ginkgo biloba, used ginseng root should be avoided medication use cautiously. The fact by a large number of during nursing. that herbal products are promoted as people to combat • Siberian Ginseng: “natural” does not imply that they 21 decreased memory Siberian ginseng, also called are always safe to use. Unlike and concentration, Eleuthero root, contains conventional medications, herbal and dementia. eleutherosides, lignans, and products are not regulated by the Younger persons take coumarin derivatives. Like Food and Drug Administration and Ginkgo to enhance Ginseng root, this drug claims to are not subject to its Good learning ability. enhance mental capacity. The Manufacturing Practice guidelines. Dosage recommendations range tonic is also advertised to invigorate Therefore, a lack of standardization from 120–240 mg a day in two to during times of fatigue. The dose, exists among herbal medications. In three divided doses. Treatment though, is different from Ginseng addition, an active or harmful ingre- should last at least eight weeks in root. Eleuthero root requires 2–3 dient may be more or less cases of organic brain disease. Other grams daily in either an extract or a concentrated in a particular plant uses should be limited to 6–8 weeks tea for up to three months.10 One depending on where, when, and on a one-time basis to determine if report claiming androgenization of how the herb was harvested. These any therapeutic benefits exist. No an infant in a pregnant mother inconsistencies can lead to fluctua- apparent information on breastfeed- taking Siberian ginseng is in the liter- tions in efficacy and to potentially ing and Ginkgo biloba exists.10 It is a ature.19 Little is known regarding harmful side effects in the mother known platelet inhibitor and may eleutherosides and breastfeeding. and/or nursling. affect coagulation processes in the Until more information is available, Little is known about side mother and the nursling. Therefore, Siberian ginseng should be avoided effects of herbals. There have been it should be used with caution, espe- during nursing. reports of specific herbal side effects, cially in infants with cardiovascular but there are a lack of a standardized disease. SLEEP PREPARATIONS reporting mechanisms for herbals. Ginseng: Ginseng is a name Melatonin: Melatonin is a The information presented in this that includes two very different widely used medicinal for the treat- article can serve as a general guide- groups of herbs. The first is the tradi- ment of insomnia and jet lag. A line for breastfeeding mothers. tionally known ginseng, from the naturally occurring compound However, the use of any medication Panax family. The second group orig- secreted by the pineal glands, mela- while breastfeeding is only recom- inates from the Eleutherococci tonin aids in the regulation of the mended if patients have a real

COMMUNICATION SEPTEMBER/OCTOBER 2001 15 Herbals and Breastfeeding medical need for treatment. 3. Wright A, Bauer M, Naylor A, et al. Increasing 12. Shoup J, Carson DS. Anticoagulant use during breastfeeding rates to reduce infant illness at the lactation. J Hum Lact, 15(3):255-7, 1999. Conventional medications should be community level. Pediatrics, 101(5):837-44, 1998. 13. Menella JA, Beauchamp GK. Maternal diet considered first-line therapy because 4. Whorwell P, Holdstock G, Whorwell G, et al. alters the sensory quantities of human milk more clinical studies and data exist Bottle feeding, early gastroenteritis, and inflam- and the nursling’s behavior. Pediatrics, 3(2): matory bowel disease. Brit J Med, Feb: 382, 93-100, 1991. for conventional therapy during 1979. 14. Menella JA, Beauchamp GK. The effects of nursing. 5. Mayer EJ, Hamman RF, Gay EC, et al. Reduced repeated exposure to garlic-flavored milk on Currently, not all healthcare risk of IDDM among breast-fed children: The the nursling’s behavior. Ped Res, 34(6): 805-8, Colorado IDDM Registry. Diabetes, 37:1625-32, 1993. professionals have sufficient knowl- 1988. 15. Miller LG. Herbal medicinals: selected clinical edge of alternative therapies and 6. Koletzo S, Sherman P, Corey M, et al. Role of considerations focusing on known or potential infant feeding practices in development of drug-herb interactions. Arch Intern Med, herbal medications. By enhancing Crohn’s disease in childhood. Brit J Med, 158(20):2200-11, 1998. their overall knowledge of herbal 298:1617-8, 1989. 16. Patton SB, Love EJ. Drug-induced depression: products and their role in patient 7. Davis M, Savitz D, Graubard BI. Infant feeding incidence, avoidance and management. Drug and childhood cancer. Lancet, 1988 Aug:365-8, Saf, 10(3):203-19, 1994. care, pharmacists can be a valuable 1992. 17. Howard CR, Lawrence CA. Drugs and breast- asset for improving pharmaceutical 8. Nice FJ. Breastfeeding and over-the-counter feeding. Clin Perinatol, 26(2):447-78, 1999. care for breastfeeding mothers. medications. Pharmacy Times, 58:114-24, 126-7, 18. Review of Natural Products, Facts and 1992. Comparisons. St. Louis, Walter Kluwer 9. Tyler V. Herbs of Choice: The Therapeutic Use Company, 1996. of Phytomedicinals. Binghamton, NY: 19. Koren G, Randor S, Martin S, et al. Maternal REFERENCES Pharmaceutical Products Press, 1994. ginseng use associated with neonatal androge- 1. Ryan A. The resurgence of breastfeeding in the 10. Blumenthal M, Gruewald J, Hall T, Riggins C, nization. JAMA, 264:2866, 1990. United States. Pediatrics, 99(4):E12. Abstract. Rister R. The Complete German Commission E 20. Guardiola-Lemaitre B. Toxicology of mela- 1997. Monographs: Therapeutic Guide to Herbal tonin. J Biol Rhythms, 12(6):697-706, 1997. Medicines. Austin, TX: American Botanical 2. Scariati P, Grummer-Strawn L, Fein S. A longitu- 21. Chang J. Medicinal herbs: drugs or dietary Society, 1998. dinal analysis of infant morbidity and the extent supplements? Biochemical Pharmacology, 59: of breastfeeding in the United States. Pediatrics, 11. Kopec K. Herbal medications and breastfeed- 211-219, 2000. 1997, 99(6):E5. Abstract. 1997. ing. J Hum Lact, 15(2):157-61, 1999.

16 COMMUNICATION SEPTEMBER/OCTOBER 2001