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The use of a medication by the breastfeeding mother common reason for unnecessarily stopping breastfeeding. The use of a medication by the breastfeeding.

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Presentation on theme: "The use of a medication by the breastfeeding mother common reason for unnecessarily stopping breastfeeding. The use of a medication by the breastfeeding."— Presentation transcript:

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4 The use of a medication by the breastfeeding mother common reason for unnecessarily stopping breastfeeding. The use of a medication by the breastfeeding mother continues to be a common reason for unnecessarily stopping breastfeeding. because the mother gets incorrect advice as to what drugs are safe for the breastfed infant. Usually this occurs because the mother gets incorrect advice as to what drugs are safe for the breastfed infant. The goal to provide the necessary therapeutic compounds to the breastfeeding mother minimizing the amount of drug passed through the milk to the child The goal of successful maternal therapy during lactation is to provide the necessary therapeutic compounds to the breastfeeding mother while minimizing the amount of drug passed through the milk to the child, and those amounts that are transferred do not cause any significant changes in the child.

5 There are s ss several factors that e ee enhance drug transfer into human milk, including l low molecular weight h high lipid solubility l long half-life ow protein binding d drug metabolites with long half-life a acid-base characteristics that favor the transfer of weak bases. Pharmacologic Principles

6 Intestinal drug absorption may be Intestinal drug absorption may be unpredictable in the neonatelower gastric unpredictable in the neonate due to lower gastric pH. pH. The neonate may have : The neonate may have : less protein binding of drugs less protein binding of drugs greater blood-brain barrier permeability greater blood-brain barrier permeability less body fat to store drugs less body fat to store drugs The neonate with delayed renal and hepatic clearance of drugs, The neonate with delayed renal and hepatic clearance of drugs, is exposed to even greater effects when the mother uses medication with active is exposed to even greater effects when the mother uses medication with active metabolites. metabolites. Pharmacologic Principles

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8 exposes the infant to nicotinecyanide carbon monoxidedirectly via milk indirectly by passive smoking. Cigarette smoking exposes the infant to nicotine and other compounds, including cyanide and carbon monoxide, directly via milk and indirectly by passive smoking. effect milk production impair let-downbehavioral changes in the infant. Cigarette smoking may effect milk production, impair let-down, and result in behavioral changes in the infant. Drug Categories CigaretteCigarette

9 Pregnancy and lactation are opportune times on smoking cessation Pregnancy and lactation are opportune times to counsel the mother on smoking cessation to protect her health as well as her infant's. nicotine appears in milk slight risk the breastfed infant exhibit signs of restlessness, jitteriness, poor feeding, and abnormal sleep patterns. Because nicotine appears in milk, there is a slight risk that the breastfed infant may exhibit signs of restlessness, jitteriness, poor feeding, and abnormal sleep patterns. breastfeeding should be encouraged because of its protection against respiratory illnesses are more common in the infant living in a home with smokers. Despite these concerns, breastfeeding should be encouraged because of its protection against respiratory illnesses, which are more common in the infant living in a home with smokers. CigaretteCigarette

10 rapid transport into milk lipid-soluble not ionizedhas low molecular weight Concentrations in milk are very close to maternal plasma concentrations. Ethanol is one prototype of drug demonstrating rapid transport into milk. It is lipid-soluble, is not ionized, and has low molecular weight. Concentrations in milk are very close to maternal plasma concentrations. decrease the amount of milk ingested by the infant. There is evidence that the consumption of alcohol by the mother may decrease the amount of milk ingested by the infant. Chronic drinking may diminish milk production. Chronic drinking of alcoholic beverages may diminish milk production. Alcohol

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12 the amount in milk is usually less than 1% of the amount ingested by the mother. Caffeine is transferred but the amount in milk is usually less than 1% of the amount ingested by the mother. no caffeine is detected urine up to 3 cups of coffee a day unlikely infant has measurable exposure to caffeine. Because no caffeine is detected in the infant's urine with maternal consumption of up to 3 cups of coffee a day, it is unlikely that the infant has measurable exposure to caffeine. Caffeine

13 Drugs of abuse are contraindicated for breastfeeding mothers. Drugs of abuse are contraindicated for breastfeeding mothers. Drugs of abuse

14 Unfractionated and low molecular weight heparin are safe because they do not cross into milk. Unfractionated and low molecular weight heparin given to the mother are safe for the breastfed infant because they do not cross into milk. Warfarin safe very high binding of the drug to maternal plasma protein.Warfarin is also safe because of its very low concentration in milk due to very high binding of the drug to maternal plasma protein.AnticoagulationAnticoagulation

15 1.Steroids transferred into milk in extremely small quantities safe 1.Steroids are transferred into milk in extremely small quantities, and transfer from oral inhalers is even smaller. The use of steroids to treat asthma in the breastfeeding mother is safe for the infant. 2.Beta-agonists very small transfer to the breastfed infant be safe 2.Beta-agonists such as albuterol are associated with very small transfer to the breastfed infant and seem to be safe. 3.Theophylline will not be an issue for the breastfeeding mother 3.Theophylline is rarely used now for either prophylaxis or treatment of acute asthma and ordinarily will not be an issue for the breastfeeding mother. Irritability in the infant, however, has been reported. 4.Newer agents zileutonzafirlukast montelukast No information 4.Newer agents such as zileuton inhibit leukotriene formation, and zafirlukast and montelukast block leukotriene action. No information on their concentration in milk is available and there are no reports of effects on the breastfed infant. Asthma Therapy

16 significant risk for child development. Maternal depression, often accompanied by anxiety, carries significant risk for child development. Antidepressants alter the concentration of neurotransmitters in the CNS interneuronal space. Antidepressants are thought to alter the concentration of neurotransmitters in the CNS particularly in the interneuronal space. tricyclics nortriptyline amitriptyline good safety profile long-term infant developmental follow-up. Older antidepressants, such as the tricyclics nortriptyline and amitriptyline, have a good safety profile in breastfeeding, including long-term infant developmental follow-up.

17 serotonin selective reuptake inhibitors (SSRIs) better tolerated serotonin selective reuptake inhibitors (SSRIs), are better tolerated and are widely prescribed during pregnancy and lactation. low concentrations in human milk less than 50%of maternal plasma level. The SSRIs generally exhibit low concentrations in human milk usually less than 50%of maternal plasma level.

18 older than 4 months, may have no detectable serum levels of the drug after passage through milk. Many infants, especially older than 4 months, may have no detectable serum levels of the drug after passage through milk. younger than 4 months may have detectable levels (fluoxetine), plasma level may be close to the accepted therapeutic range for adults. Infants younger than 4 months may have detectable levels and, in the case of some drugs (fluoxetine), the infant plasma level may be close to the accepted therapeutic range for adults. a few reports restlessnessirritabilitycolicpoor weight gainsleep disorders fluoxetine. There have been a few reports of infants who exhibited restlessness, irritability, colic, poor weight gain, and sleep disorders when their mothers took fluoxetine.

19 fluoxetine sertraline accumulation may occur in the very young infant. Two often-used SSRIs, fluoxetine and sertraline, have active metabolites and half-lives that are on the order of days, and accumulation may occur in the very young infant. there are no long-term studies indicating either safety or adverse effects. The concern about exposure of the breastfed infant to these compounds is that there are no long-term studies indicating either safety or adverse effects. other SSRIsno adverse effects For the other SSRIs, no adverse effects have been described.

20 Long-acting benzodiazepines ( diazepam ) especially if associated with chronic use accumulate in milkproduce symptoms lethargy, sedation, and poor suck. Long-acting benzodiazepines ( diazepam ), especially if associated with chronic use, may accumulate in milk and produce symptoms in the infant, such as lethargy, sedation, and poor suck. Sporadic use of long-acting drugs use of short-acting drugs (lorazepam, midazolam, oxazepam) pose less of a risk. Sporadic use of long-acting drugs and the use of short-acting drugs (lorazepam, midazolam, oxazepam) pose less of a risk.

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22 generally does not present any concerns for breastfeeding. breastfeeding may reduce maternal insulin needs. Diabetes therapy generally does not present any concerns for breastfeeding. In some cases, breastfeeding may reduce maternal insulin needs. Insulin does not cross into human milk. Insulin does not cross into human milk. Oral Hypoglycemics are little data concerning There are little data concerning the use of the oral hypoglycemics and virtually none on newer agents. Tolbutamide compatible with breastfeeding. Tolbutamide is usually compatible with breastfeeding. Other drugs should be used with caution by mothers who breastfeed. Other drugs should be used with caution by mothers who breastfeed. Diabetes therapy

23 can result in severe prolonged hypoglycemia in the newborn. This is based on the experience with their use in pregnancy, which can result in severe and prolonged hypoglycemia in the newborn. The best advice avoid them until lactation is well established infant is gaining weight satisfactorily the need to monitor the infant's blood glucose. The best advice for using these agents during lactation is to avoid them until lactation is well established, the infant is gaining weight satisfactorily, and the parents discuss with the pediatric care professional the need to monitor the infant's blood glucose. glyburide poor transplacental transfer of this drug likely due to high protein binding and a short elimination half-life. Newer data on glyburide are encouraging. There is poor transplacental transfer of this drug likely due to high protein binding and a short elimination half-life. For the same reason, there may be limited transfer into milk. Until safety during lactation is established howeverthese agents also should be used with caution. Until safety during lactation is established, however, these agents also should be used with caution. Diabetes therapy

24 H 2 receptor blocking agents famotidine, ranitidine, and cimetidine safe H 2 receptor blocking agents ( famotidine, ranitidine, and cimetidine ) seem to be safe during lactation. given directly to young infants treat reflux hospitalized children to decrease production of gastric acid minimize the occurrence of peptic ulcers. All of these compounds have been given directly to young infants to treat reflux and in hospitalized children to decrease production of gastric acid and minimize the occurrence of peptic ulcers. omeprazole quite safe Likewise, the use of the protein pump inhibitor omeprazole also seems to be quite safe during lactation, although concentrations in milk have not been documented.GERDGERD

25 (Crohn disease, ulcerative colitis) multiple medications The treatment of inflammatory bowel disease (Crohn disease, ulcerative colitis) may require the use of multiple medications. corticosteroids enemaorally anti-inflammatory drugs sulfasalazinemesalamine olsalazine. These include corticosteroids (by enema and orally) and anti-inflammatory drugs such as sulfasalazine, mesalamine, and olsalazine. is rapidly cleared from the plasma if it does appear in milk, it is in very low concentrations. This substance is rapidly cleared from the plasma of adults and if it does appear in milk, it is in very low concentrations. Inflammatory Bowel Disease

26 antimetabolite 6- mercaptopurinemethotrexate IBD occasionally may be treated with an antimetabolite drug, such as 6- mercaptopurine or methotrexate. contraindicated during breastfeeding because of potential cytotoxicity. Previous editions of the AAP policy statement reported that these drugs were contraindicated during breastfeeding because of potential cytotoxicity. no data to support this amount transfer However, there exist no data to support this, and the amount transferred may be inconsequential to the baby. should not be given informing the parents about the possible immune suppression and effects on growth These drugs should not be given to lactating mothers without fully informing the parents about the possible immune suppression and effects on growth, even in small amounts, to the breastfed infant. should be monitored for neutropenia. If used, the infants should be monitored for neutropenia. Inflammatory Bowel Disease

27 often combinations of drugs The treatment of adult hypertension often involves combinations of drugs. Currently there are 4 classes of antihypertensive drugs that are used: 1) diuretics, 1) diuretics, 2) beta blocking agents, 2) beta blocking agents, 3) angiotensin converting enzyme 3) angiotensin converting enzyme inhibitors (ACEI) inhibitors (ACEI) 4) calcium channel blocking agents. 4) calcium channel blocking agents. Hypertension

28 Diuretics safe Hydrochlorothiazide and chlorothiazide used for decadesDiuretics Seem to be safe during lactation. Hydrochlorothiazide and chlorothiazide have been used for decades and no problems have been described in the breastfed infant. Beta-Blocking Agents within this class safest for use propranolol, sotalolmetoprolol.Beta-Blocking Agents. The drugs within this class that seem to be safest for use during pregnancy are propranolol, sotalol, and metoprolol.HypertensionHypertension

29 Atenolol acebutololproblems to the breastfed infant. Atenolol and acebutolol may present problems to the breastfed infant. cyanosis and bradycardia 5-day-old infant One case report describes cyanosis and bradycardia in a 5-day-old infant whose mother was receiving atenolol. It is prudent to avoid atenolol and acebutolol in the breastfeeding mother It is prudent to avoid atenolol and acebutolol in the breastfeeding mother should be monitoredheart rate feeding problemsrespiratory patternactivity The infant of any mother who needs to take a beta-blocking agent should be monitored, especially for heart rate, feeding problems, respiratory pattern, and activity.HypertensionHypertension

30 ACE inhibitors no reports of problems ACE inhibitors are excreted in limited quantities into milk. There are no reports of problems using these drugs. Calcium channel blocking agents it does seem that nifedipine is excreted in small amounts Calcium channel blocking agents are the newest of the antihypertensive agents. Little is known about their excretion in milk, but it does seem that nifedipine is excreted in small amounts and is safe during breastfeeding. safe during breastfeeding. These drugs also is probably safe during breastfeeding.HypertensionHypertension

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32 the most frequent cause for the use of drugs in the lactating woman. Infectious disease treatment is probably the most frequent cause for the use of drugs in the lactating woman. all antibiotics are transferred to milk Many of them are also used for the treatment of infectious diseases in pediatrics. Generally, all antibiotics are transferred to milk. Many of them are also used for the treatment of infectious diseases in pediatrics. The doses received by the breastfed infant always are less than what would be given directly to the infant for therapy. The doses received by the breastfed infant always are less than what would be given directly to the infant for therapy. Infectious disease

33 Sulfonamidesshould not be given breastfeeding mother whose infant is jaundiced in the age group where jaundice may develop Sulfonamides should not be given to a breastfeeding mother whose infant is jaundiced or in the age group where jaundice may develop. displacement of bilirubin from albumin in the infant's plasma by sulfonamides may increase the risk of kernicterus. This is because of the possible displacement of bilirubin from albumin in the infant's plasma by sulfonamides, which may increase the risk of kernicterus. increase the risk of hemolysis G6PD In addition, there are concerns that these drugs may increase the risk of hemolysis in infants with a deficiency of G6PD. Infectious disease

34 Tetracycline. cautioning against the use of tetracycline during breastfeeding. Tetracycline. There are numerous statements in reviews of drugs in milk cautioning against the use of tetracycline during breastfeeding. The amount of tetracycline that might appear in milk is extremely lowno reports of adverse effects infant's GI tract calcified tissues, such as bone and teeth. The amount of tetracycline that might appear in milk is extremely low, and there are no reports of adverse effects on the infant's GI tract or on calcified tissues, such as bone and teeth. are not commonly used replaced by more effective and safer antibiotics. Tetracyclines are not commonly used because they have been replaced by more effective and safer antibiotics. Infectious disease

35 Metronidazole Metronidazole is occasionally used in infants Giardia some anaerobic infectionsused in pregnancy Metronidazole is an antibiotic that is occasionally used in infants for the treatment of Giardia and some anaerobic infections, and is used in pregnancy. safe Metronidazole seems to be safe for the breastfed infant. Infectious disease

36 Quinolone (nalidixic acid) (ciprofloxacin, ofloxacin) long half- livesonce-or twice-a-day dosing. Quinolone (nalidixic acid) and fluoroquinolone (ciprofloxacin, ofloxacin) antibiotics have reasonably long half- lives, which allow once-or twice-a-day dosing. well absorbed from the GI tract permitting the early switch from intravenous to oral therapy discharge They are well absorbed from the GI tract, permitting the early switch from intravenous to oral therapy and hence discharge from the hospital and increased compliance. Infectious disease

37 may interfere with cartilage formation in juvenile mammals. Some of these drugs may interfere with cartilage formation in juvenile mammals. a warning label are not to be used in anyone younger than 18 years. This has resulted in a warning label that they are not to be used in anyone younger than 18 years. some pediatric studies long-term use in patients with cystic fibrosis not shown any cartilage damage However, some pediatric studies involving long-term use in patients with cystic fibrosis have not shown any cartilage damage as measured by serial MRI of joints. Infectious disease

38 ciprofloxacin is approved limited use in children nalidixic acid for more than 30 years Furthermore, ciprofloxacin is approved for limited use in children and the oldest quinolone, nalidixic acid, has been labeled for pediatric use for more than 30 years, although it is now rarely used in the pediatric population. no reported adverse effects of this drug on growth. There have been no reported adverse effects of this drug on growth. transferred into human milk is extremely low if there is no other choice for maternal therapy, a short (1-to 2-week) exposure to quinolones may be acceptable The amount that would be transferred into human milk is extremely low and if there is no other choice for maternal therapy, a short (1-to 2-week) exposure to quinolones may be acceptable for the breastfed infant. Infectious disease

39 Antifungal agents fluconazole safe Antifungal agents currently given orally, including fluconazole, are safe for the infant and have been used for direct infant therapy. Infectious disease

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41 prophylaxis treatment of the acute episode. Treatment in adults is divided into prophylaxis of attacks and treatment of the acute episode. range nonpharmacologic measures rest, darkened room, and a wet cloth to the forehead newest drugs. The initial therapy for acute migraine headache may range from nonpharmacologic measures, such as rest, darkened room, and a wet cloth to the forehead, to some of the newest drugs.

42 acetaminophen (NSAIDs)acceptable during lactationmost are weak acids and highly protein bound. The use of acetaminophen and nonsteroidal anti- inflammatory drugs (NSAIDs) is acceptable during lactation because most are weak acids and highly protein bound. ibuprofennaproxen ketoprofen The NSAIDs include ibuprofen, naproxen, and ketoprofen. There are products that contain a combination of acetaminophen with caffeine. All of these safe All of these compounds are safe during lactation. only a small fraction of the dose given to infants for fever and pain. The amount of acetaminophen and/or ibuprofen that might be transferred during lactation is only a small fraction of the dose given to infants for fever and pain.

43 The Triptan family sumatriptannaratriptan rizatriptanzolmitriptan the excretion in milk is extremely low The Triptan family contains the following compounds: sumatriptan, naratriptan, rizatriptan, and zolmitriptan. The only one for which data exist is sumatriptan, and the excretion in milk is extremely low and has not caused adverse effects in the breastfed infant.

44 The Ergot family : The Ergot family : (IV) form dihydroergotamine a very long half-life The intravenous (IV) form of ergotamine is dihydroergotamine, which has a very long half-life. oral ergot methysergide An oral ergot is methysergide. may inhibit prolactin release not to use drugs in the ergotamine family during lactation. Ergotamines may inhibit prolactin release and thus interfere with lactation. Because alternatives exist with the triptan family, it is prudent not to use drugs in the ergotamine family during lactation.

45 Pain management Can be achieved appropriate doses acetaminophen NSAIDs Pain management Can be achieved by appropriate doses of either acetaminophen or NSAIDs such as ibuprofen and naproxen. More severe pain immediately after birth or after surgery morphine because morphine has primarily inactive metabolites. More severe pain, such as that occurring immediately after birth or after surgery, is best managed with the use of appropriate doses of morphine because morphine has primarily inactive metabolites.

46 Phenobarbital low protein binding sedation in breastfed infants exposed to the drug through milk. Phenobarbital has low protein binding, and sedation has been reported in breastfed infants exposed to the drug through milk. carbamazepinevalproic acid the addition of lamotrigine or tiagabine Most adults receive carbamazepine or valproic acid as single drug agents with the addition of lamotrigine or tiagabine for complex seizure disorders. Seizure Management

47 There are single case reports that indicate infant problems. Cholestasiscarbamazepine thrombocytopenia and anemia valproic acid. Cholestasis with carbamazepine has been reported, and thrombocytopenia and anemia with valproic acid. methemoglobinemia phenytoin. An older publication has described methemoglobinemia in the infant of a mother taking phenytoin. Lamotrigine with therapeutic levels in the infant. Lamotrigine taken by the breastfeeding mother may be associated with therapeutic levels in the infant. Seizure Management

48 not only to clinically observe the baby but also to measure drug concentrations in very young infants in the first 2 months of life. Regardless of which drug or drugs the mother needs for the control of her epilepsy, it would be prudent not only to clinically observe the baby, but also to measure drug concentrations in the infant's plasma on a regular basis, especially in very young infants in the first 2 months of life. Seizure Management

49 (levothyroxine) transmitted into milk in extremely small quantities will not change the thyroid function of the infant. (levothyroxine) is transmitted into milk in extremely small quantities and will not change the thyroid function of the infant. hyperthyroidism propylthiouracil methimazole. Women with hyperthyroidism have a choice of 2 drugs for therapy: propylthiouracil and methimazole. Propylthiouracil is the preferred drug 75% of it is bound to maternal plasma protein no protein binding. Propylthiouracil is the preferred drug because about 75% of it is bound to maternal plasma protein in contrast to methimazole, which has almost no protein binding. amount of propylthiouracil secreted is quite small. Thus the amount of propylthiouracil secreted is quite small. less than 1% of the therapeutic dose goes to the infant. usually less than 1% of the therapeutic dose goes to the infant.

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51 Thyroid function of the infant is not altered by maternal use of propylthiouracil. Thyroid function of the infant is not altered by maternal use of propylthiouracil. chronic ingestion iodides,low molecular weighttransferred to milk in the infant may interfere with thyroid function. With chronic ingestion, iodides, being of low molecular weight, may be transferred to milk and in the infant may interfere with thyroid function. Occasional doses may not be a problem. Occasional doses, however, used to protect the thyroid may not be a problem. Chronic use of iodine-containing cough and cold medications should be avoided. Chronic use of iodine-containing cough and cold medications should be avoided.

52 I f a d dd diagnostic radioisotope is to be administered to a breastfeeding mother, s ss she should be told how long she likely is to be unable to breastfeed, based on the half-life of the radioisotope chosen. T his will allow her to e ee express and freeze milk in advance f ff for her infant's use while she is unable to breastfeed.

53 When she stops breastfeeding she should be counseled to express and discard her milk during the time required for treatment. When she stops breastfeeding temporarily (for example hours for some thyroid scans), she should be counseled to express and discard her milk during the time required for treatment. therapeutic radioactive isotopes not be able to breastfeed because the dose of radiation remains high for a sustained period. Mothers who receive therapeutic radioactive isotopes will probably not be able to breastfeed because the dose of radiation remains high for a sustained period.

54 Galactagogues stimulate the production of milk. Galactagogues are drugs that stimulate the production of milk. should be used in conjunction with usual efforts to increase milk production frequent breastfeeding milk expression Galactagogues should be used in conjunction with usual efforts to increase milk production ( frequent breastfeeding and milk expression ).

55 Metoclopramide commonly is used to increase milk production early in lactation or at any time when milk production seems to be falling. Metoclopramide commonly is used to increase milk production early in lactation or at any time when milk production seems to be falling. Short-term use of metoclopramide safe Short-term use of metoclopramide (usually not exceeding 14 days) seems safe. multiple effects on the mother's CNS, including sleepiness, depression, or extrapyramidal signs. Studies differ as to the success in sustained increase in milk production with this drug. The drug may have multiple effects on the mother's CNS, including sleepiness, depression, or extrapyramidal signs. Short-term use of metoclopramide seems safe because it seldom is used for more than 14 days.

56 Oxytocin spray available in the pa but it is no longer manufactured. Oxytocin spray (40 IU/mL) was commercially available in the past to improve milk ejection, but it is no longer manufactured. Some practitioners have used the available dilute intravenous oxytocin (10 IU/mL) as nasal drops or spray (4 drops instead of 1). Oxytocin spray available in the pa but it is no longer manufactured. Oxytocin spray (40 IU/mL) was commercially available in the past to improve milk ejection, but it is no longer manufactured. Some practitioners have used the available dilute intravenous oxytocin (10 IU/mL) as nasal drops or spray (4 drops instead of 1).

57 Herbal Remedies Many cultures have relied on herbs and other substances to improve milk production. Many cultures have relied on herbs and other substances to improve milk production. There have been no scientific studies of these preparations to prove or disprove their value as galactagogues.

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