Complementary and alternative methods of increasing breast milk of mothers of children aged 0-24 months

Introduction and aim. Some applications are made to increase the breast milk. This study has been conducted to determine the complementary and alternative methods to increase the breast milk of mothers with a child in the age of 0 to 24 months. Material and methods. This study was conducted using the cross-sectional study design. The questionnaire included mothers’ socio-demographic characteristics, obstetric histories, breastfeeding, and practices to increase breast milk. Results. The mean age of the mothers was 29.75±5.97 years. 23.4% of the mothers stated that they did not continue breastfeeding; the mean duration of breastfeeding was 9.24±4.88 months. Mothers expressed to increase milk intake water/liquid food to increase (84.2%), frequently breastfed babies (43.3%), boiling greens to drink (34.6%), spiritual practices (12.8%). Mothers stated that the special drinks used to increase their milk were fennel (56.2%), instant milk enhancer (22.9%), and sage (8.9%). Mothers emphasized that the amount of water (85.1%) and sugar levels (50.0%) they consumed the most increased breast milk. Conclusion. It was determined that children could not have enough breast milk until the age of two; the mean duration of breastfeeding was low. Mothers believe that their breast milk is not enough for their children, so they apply milk-increasing practices.


Introduction
Breast milk is essential for laying the foundation of a healthy life, particularly when given exclusively during the first six months after birth and with supplementary food after that during the first two years. 1 Breast milk has been the most natural and healthiest resource of baby feeding since the beginning of time. Unfortunately, like all-natural life-supporting resources, breast milk is also wasted due to wrong information, attitude, and behaviors. The benefit of breast milk is affected by the duration of use and exclusive use. Stimuli or experienced trauma when life is the most critical or sensitive with regards to nutritional programming affect the rest of life in the long term. [2][3][4][5] The 2015 report of the Centers for Disease Control and Prevention (CDC) reveals that 83.2% of babies start to get breastfeeding while 24.9% of them are exclusively breastfed during the first six months, and 17.2% of them are fed with formula in the first two days of their life. 6 In Turkey, 98% of the babies are breastfed for "a while, " and 42% of them are fed with food other than breast milk. The median time for exclusive breastfeeding is 1.8 months; supplementary foods are started for babies in the early period. 7 These results indicate that babies are not at the desired level to create and maintain healthy nutrition.
Mothers' feeding methods are determined by various socio-economic, cultural, and personal factors. There are various factors with negative effects on the start of breastfeeding in the postnatal period and on the continuation of healthy nutrition period, including baby-related factors (crying, colic pain, breast refusal, etc.) and mother related factors (age, education, employment, attitude against breastfeeding, anxiety, breast problems, considering that milk is insufficient, traditional practice, etc.). 8,9 Providing plenty of breast milk and latching the baby on the breast during the first postnatal days are critical tasks. The reasons for cessation of breast milk in an early period include the concern of mothers that breast milk is not sufficient for the baby. Getting colostrum away from the breast through effective breastfeeding after birth and exclusive breastfeeding from the first day on may provide the production of breast milk to meet the baby's needs. 5,10-12 Although every mother's breast milk production at levels sufficient for her baby, researches shows that mothers believe that their milk is not sufficient and resort to complementary and alternative methods (CAM) to increase their milk. 13 The uses of complementary and alternative methods, including herbal medicines, are increasing dramatically in the general population worldwide. 14 Studies highlight that alternative methods considered galactagogues, including herbs, herbal teas/medicines, special food, massage, music, acupuncture, and heat, are popular among breastfeeding women despite the lack of data on their efficacy and safety. 8,15,16 Mothers are asked to carry out various practices to increase breast milk, and it is attempted to continue the nutrition of babies with supplementary food since birth. In this process, mothers' milk is reduced, babies cannot feed with breast milk, and both mothers and babies face various health problems. 17,18 Health services to individuals and families to provide and maintain breastfeeding are essential to lay the foundations of healthy nutrition. Knowledge of beliefs and practices to increase breast milk will determine the priorities, particularly in this period. 19 The complementary and alternative methods applied to increase breast milk should be selected, and then their adequacy and efficacy should be investigated by evidence-based studies. 18,20 Ineffective, insufficient, harmful, or unnecessary practices that are believed to increase breast milk should be avoided.

Aim
This study has been conducted in order to determine the complementary and alternative methods that are believed to increase breast milk of mothers with a child in the age of 0 to 24 months.

Study design and participants
The present hospital-based cross-sectional study was conducted in pediatric wards of a tertiary care teaching institution from March 15, to June 15, 2019 in Turkey. The sample size was computed using the following formula: [n=z 2 pq/d 2 ]. (n=sample size, z=(1−α), is the z-score corresponding to a 95% confidence interval and was computed as 1.96, p=0.50, q=(1−p)=0.50, d=desired margin of error or 0.05.) The estimated sample size was 384. However, to cover for possible dropouts due to missing information on crucial questions, a total of 436 participants were recruited for the study. Purposive sampling method was used in the study. The sample group consists of the mothers with a child in the age of 0 to 24 months in the institution where the study was conducted and 436 mothers were included in the study during the data collection dates (a period of 3 months). The study was conducted with the mothers with a child in the age of 0 to 24 months since the importance of breast milk for the first two years in baby nutrition is emphasized.

Data collection tools
In this study, a questionnaire form prepared in line with the literature was used as a data collection tool. Data collection tool consists of 47 questions including socio-demographic qualities of mothers (13 questions), obstetric histories (9 question), breastfeeding conditions (15 questions) and practices of mothers to increase breast milk (10 questions). 1,4,8,13,16 The researcher obtained the consent of mothers to collect data and their convenient times were determined. Data was collected by the researcher through face-to-face interview method within 30 to 40 minutes in average in an appropriate meeting room.

Ethics approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Ethics Committee of University of Giresun (Date: 19.12.2018/No: 08-16).

Statistical analysis
Statistical analyses were performed using the statistical software package SPSS version 20 for Windows (IBM, New York, USA). Means, standard deviations, percentages, and frequencies were used for descriptive analysis.

Results
The average age of mothers in the study was 29.75±5.97 years (18-45 years), and more than half of them (58.9%) are in the group of 30 years and younger. More than half    (1)(2)(3)(4)(5)(6). More than half of the babies were girls, 38.8% are between 0 to 6 months, 35.8% were between 7 to 12 months, and 25.5% were between 13 to 24 months. In the study, most participants (68.6% ) stated that they breastfed their babies in the first 30 minutes after giving birth, 26.4% in the first 30 to 60 minutes, 5.0% 1 hour later after giving birth. The majority of the mothers (91.3%) stated that they breastfed first as the first nutrition of the baby, 3.4% gave Zamzam water, 2.3% gave water, 2.1% showed a formula, and 0.9% gave sugared water (Table 1).
One-fourth of mothers (23.4%) said they were not currently breastfeeding, while the average breastfeeding duration was 9.24±4.88 months (2 to 24 months). The participants stated that the reason for ending breastfeeding was ablactation and insufficient breast milk (15.8%), breast refusal (6.7%), separation from baby (6.2%), unwillingness to breastfeed (4.6%) and other reasons. The time to start supplementary food is 5.56±1 months on average (3 months to 12 months). More than half of the participants (60.1%) stated that their milk was not sufficient due to factors including extreme stress (38.2%), insufficient nutrition (31.3%) and, resuming work (16%) ( Table 1).

Discussion
Nutrition with breastfeeding is the first and the most step of healthy food. Breastfeeding is widespread and traditional in Turkey. However, exclusive breastfeeding for the first six months and breastfeeding is problematic. Breastfeeding mothers often believe that their milk is sufficient. 21 Breastfeeding babies frequently and through correct techniques, emptying the breasts, adequate sleep, and resting, and increasing mothers' self-confidence is reported to be effective practices in increasing breast milk. However, there are various cultural applications in practice. [22][23][24] This study helps determine complementary and alternative galactagogue methods.
The early start of breastfeeding is helpful for both mother and baby. Skipping this early postnatal period of the first half an hour harms the success and duration of breastfeeding. 25,26 The study revealed that mothers didn't breastfeed their babies in the first half an hour. Senarath et al. found that only 46.1% of mothers started breastfeeding in the first one hour. 27 Bergamaschi et al. reported that the breastfeeding ratio of mothers in the first one hour was 50% and that 61% of babies were not exclusively breastfed in the first three days. 26 Turkey Demographic and Health Survey (TDHS) 2018 data indicated that 71% of babies were breastfed in 1 hour. 7 In the present study, 53.2% of mothers stated that they exclusively breastfed their older child for the first six months. Exclusive breastfeeding for the first six months was reported in similar studies to be 30.7% by Senarath et al., 37.3% by Ukegbu et al., % ten by Mateus Solarte and Cabrera Arana and, 28.5 % by Osibogun et al. [27][28][29][30] The ratio of exclusively breastfed babies in the first six months in Turkey is 40.7%. 7 UNICEF emphasizes that early breastfeeding of babies after birth is helpful for mothers and babies and that babies need to be breastfed in the first 30 minutes after birth. 1 Pieces of training should continue on the necessity of early start of mother-baby contact, breastfeeding babies in the first half an hour, and having breast milk as babies' first food.
World Health Organization (WHO) recommends that babies continue to be breastfed until two years of age. 1 The present study found the average breastfeeding duration of babies to be low (9.24±4.88). Similarly, there are increases in the ratio of starting breastfeeding in several countries; however, data show that few women continue breastfeeding for the recommended duration, especially in developed countries. 31 In the present study, the reasons to end breastfeeding included primarily ablactation/insufficient breast milk followed by breast-related problems. The studies in this field indicate that most mothers believe that their milk is inadequate for their babies. Hence, they start supplementary food early (before six months) and primarily use formula and other liquid food as supplemental food. 5,10,21,32 While more than 50% of breastfeeding mothers perceive that their milk is insufficient, only five percent of them have physiological milk deficiency. The reason for mothers' perception of insufficient milk is their misinterpretation of infant behavior and their lack of confidence in their ability to breastfeed. 33 Mothers stated that they understood that their milk was not enough because 74.6% of their babies were restless, 23.7% of their babies did not gain enough weight and 1.7% of them were not active. Reliable signs of insufficient breast milk are insufficient weight gain and insufficient urination. 19,27 This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY 4.0) license.
The most critical problem at this stage is that mothers start different searches just on the assumption that their breast milk is insufficient without really finding out that their breast milk is inadequate. The study revealed that mothers intended to breastfeed their babies for the first six months exclusively; however, they started supplementary food early. This indicates that mothers have a positive attitude, but they fail in practice. Therefore, this demonstrates the need to support mothers concerning breastfeeding, breast milk, and its sufficiency.
Several studies reported that mothers applied traditional galactogogues methods rather than modern ones and that those methods need evidence. 13,24,34 The present study revealed that almost all mothers used complementary and alternative approaches to increase their milk. Sibeko et al. found that mothers used herbal tea by 56%, commercial galactogogues product by 13%, and ginger/ beer by 3% to increase their milk. 32 In a qualitative study by Sim et al. with breastfeeding women on the use of herbal galactagogues, it was found that all women used fenugreek, three of them used a mixture of fenugreek and blessed thistle, and seven of them used "lactation tincture" including herbal components in their breastfeeding period. 20 Mothers stated that they were not against the idea of using herbal items and found them to be safer than chemicals and pharmacologic medicines. 34 In another study, it was reported that 69% of the lactation counselors heard about galactogogues herbal drugs, that 65% of the recommended one or more of these methods despite the lack of evidence on the methods and that they recommended most commonly fenugreek and blessed thistle as a galactogogues product. 4 Various herbs and foods are known to be used as galactagogue, including almond, aniseed, asparagus, cumin, chicken soup, coriander, coconut, dandelion, dill, fennel, fenugreek, garlic, hop, lettuce, radix althaea, millet, mushroom, stinging nettle, oat straw, daisy, rice, sage, sunflower seed, and thistle. [35][36][37] The studies conducted in Turkey revealed that the galactogogues practices are standard, including water and liquid foods, milk, and dairy products, herbs (fennel tea, stinging nettle, parsley, dill, onion, bulgur, cowpea, etc.), sugary foods (lohusa sherbet, tahini halva, milk puddings, boiled grape juice). 38,39 In the study by Dinc et al. determined the traditional galactogogues practices to be frequent breastfeeding by 29.7%, wearing blue bead and saying a prayer over it by 23.1%, consuming a lot of water by 23.1%, breastfeeding for a long time by 7.5%, having a rest by 7.1%, rubbing the breast by 6.6% and pouring lead by 2.8%. 39 It is noticed that the galactogogues practices are traditional rather than scientific. Therefore, it is evident that mothers need education and support for breastfeeding and lactation. Evidence-based studies should also be conducted for the effectiveness of the CAM used to increase milk.
Many mothers think that their breast milk is insufficient and employ various methods to increase breast milk within the traditional experience and beliefs. There is no standard information on the qualities of these methods, including use, frequency, dose, and composition. 16 There is limited literature on the complementary galactogogues methods. The complementary galactogogues methods vary among societies.

Limitations of the study
There are some limitations to our study. First, the study's design was cross-sectional, and the data did not account for assumptions concerning causation. Because cross-sectional studies involve some methodological limitations and conclusions should only be extrapolated to populations with similar characteristics. In a larger sample, multicenter and multidisciplinary studies can be planned. Secondly, our data came from self-reports. This may not avoid the subjective bias caused by individual recall.

Conclusion
The study revealed that children did not get sufficient breast milk until two years of age, average breastfeeding duration is low, and mothers start supplementary food early. Mothers believe that their breast milk is not sufficient and employ galactogogues practices. Mothers concentrate on consuming exceptional food and drinks during the lactation period, including mainly fennel tea, instant galactogogues teas, sugary foods, and water intake. It will be helpful to study the evidence-based effectiveness of the complementary galactogogues methods.
Since traditional methods are more common than modern methods to increase breast milk, training should be organized with consideration to cultural factors concerning breastfeeding, exclusively breastfeeding, and increasing breast milk. Lactation counseling should be mainstreamed; problems and solutions for the nutrition of babies should be defined and implemented to realize the breastfeeding recommendations of the World Health Organization and UNICEF. It should be remembered that lactation counseling is the most effective method to increase breast milk, and lactation problems of mothers should be solved timely with the homecare practices in the postnatal period recommending the continuation of breast milk which is necessary for babies.

What is the current knowledge?
The most crucial reason breastfeeding cannot be continued is perception of insufficient breast milk. Foods and drinks that increase breast milk (galactagogue) are used from past to present. Many foods and herbs can be counted as galactogogues. Many mothers around the world use herbs and foods to increase their milk. Although the mechanism of action of medicinal herbs and