Treatment for suppression of lactation
Bromocriptine-related and estrogen preparations are more effective than non-pharmacological methods for suppressing lactation during the first week post partum. However, the evidence supporting this finding is weak and based on small trials. When either bromocriptine-related or estrogen preparations are prescribed, prophylaxis for deep vein thrombotic events should be considered. Estrogen preparations are not recommended as the original drugs studied may not be currently available.
RHL Commentary by Tchoffo PA
1. INTRODUCTION
Women may not breastfeed their newborn babies for a variety of reasons, ranging from personal choice, HIV-infection (1), to stillbirth. Whatever the reason, the decision not to breastfeed can result in considerable breast pain, engorgement and milk secretion during the days following the delivery, until lactation is suppressed spontaneously.
Many pharmacological and non-pharmacological methods have been attempted to suppress lactation (2), but there is no evidence-based guidance on the most effective approach. This Cochrane review evaluated the effectiveness and the safety of various interventions used to suppress lactation in post-partum women who chose neither to breastfeed nor express breast milk.
2. METHODS OF THE REVIEW
All randomized controlled trails that could be identified have been included in the review. The authors followed appropriately the methodology recommended for preparing Cochrane systematic reviews.
The primary outcomes measures were: failure to suppress lactation indicated by breast engorgement or milk secretion at or within 7 days post partum or at or within 14 days post partum, as describe by the authors of articles; minor adverse effect of the drug including nausea, vomiting, headache, dizziness; major side-effect like thromboembolism, myocardial infarction and maternal death; and acceptability of the treatment to the treated women.
The secondary outcome measures were: rebound lactation; percentage of women requiring a second line or method, or both, to achieve lactation suppression; and the percentage of women requiring analgesics to relieve breast pain or discomfort.
3. RESULTS OF THE REVIEW
This review includes 46 trials involving 5164 women (regardless of parity and mode of delivery) who neither breastfed nor expressed their breast milk.
The interventions assessed included both pharmacological (drugs) and non-pharmacological methods (breast binding or strapping, firm breast support, fluid restriction, application of ice packs and external products) with the aim of suppressing lactation.
Five trials (206 women) indicated that significantly fewer women receiving bromocriptine were lactating at or within 7 days post partum compared with those who received no treatment. For this result, data were available from only three trials that could be meta-analysed [107 women; relative risk (RR) 0.36; 95% confidence interval (CI) 0.24–0.54].
Overall, six trials involving 833 women made eight comparisons of estrogen preparations with placebo and found that at or less than 7 days post partum, compared with placebo, the estrogen preparations were associated with a reduced risk of failure to suppress lactation (RR 0.41; 95% CI 0.29–0.59). High variation between studies in terms of study results (heterogeneity) was observed in this meta-analysis. Trials comparing bromocriptine with estrogen preparations (diethylstilbestrol, ethinyl estradiol, and chlorotrianisene) failed to show clear superiority of one over the other (RR 0.79; 95% CI 0.54–1.17).
One trial involving 71 women suggested a lower risk of treatment failure with a homeopathic preparation compared with placebo on days two and four post partum. There were no trials comparing other non-pharmacological methods with no treatment. Side-effects were generally not reported in the trials and no case of thromboembolism was recorded in the four trials that reported it as an outcome.
4. DISCUSSION
4.1 APPLICABILITY OF THE RESULTS
The review found that pharmacological treatments (i.e. bromocriptine-related and estrogen preparations) are more effective than non-pharmacological methods for suppressing lactation during the first week post partum. The evidence supporting this finding is weak and based on small trials, most of them old and some of them having methodological problems. Meta-analysis of trials involving estrogenic preparations revealed high heterogeneity, which weakened the strength of the evidence. Evidence related to non-pharmacological approaches was limited and weak. There is no biological or service-related reason to suppose that the results of this review will not be equally applicable in all settings.
4.2 IMPLEMENTATION OF THE INTERVENTION
Available evidence suggests that women who wish to suppress lactation should receive bromocriptine-related medications. Prophylaxis for possible deep vein thrombotic events should be considered when prescribing these drugs. Estrogen preparations are not recommended as they were studied in older trials and the original drugs may not be available currently in the market. Single-dose treatments (e.g. cabergoline – a bromocriptine-related drug) could be considered in settings where women may have difficulty in complying with multi-dose regimens.
Data on adverse effects of treatments remain scarce, but clinicians prescribing these medications should be aware of them. Nausea and vomiting are frequently observed with bromocriptine-related medications, but these symptoms are generally mild. The side-effects can reduce compliance with the treatment and can increase the failure rates. Deep vein thrombotic events and related complications are observed rarely, but when they occur these side-effects can be life-threatening. Owing to their rarity, they are unlikely to be reported in small trials. Nevertheless, the postpartum period is a high-risk period for deep vein thrombotic events and, occasionally, the indication leading to the suppression of lactation is also a high-risk condition for deep vein thrombotic events.
4.3 IMPLICATIONS FOR RESEARCH
Further larger randomized controlled trials are needed to generate more evidence to guide the health-care practice. These trials should compare pharmacological and non-pharmacological methods with no treatment. There is also a need to establish improved methods of evaluating lactation symptoms in women, acceptability to women of the interventions, as well as of notification of adverse effects of drugs.
References
- Nduati R, Richardson BA, John G, Mbori-Ngacha D, Mwatha A, Ndinya-Achola J, et al. Effect of breastfeeding on mortality among HIV-1 infected women: a randomised trial. The Lancet 2001;357:1651-1655.
- Adams Hillard PJ, ed. The 5-Minute Obstetrics and Gynecology Consult. Philadelphia, PA: Wolters Kluwer Health; 2008.
This document should be cited as: Tchoffo PA. Treatment for suppression of lactation: RHL commentary (last revised: 1 November 2009). The WHO Reproductive Health Library; Geneva: World Health Organization.