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A double-blind, randomized controlled trial on the use of malunggay

(Moringa oleifera) for augmentation of the volume of breastmilk among non-
nursing mothers of preterm infants

Article · January 2000

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ORIGINAL ARTICLES

A double-blind, randomized controlled trial on the use of malunggay

(Moringa oleifera) for augmentation of the volume ofbreastmilk among
non-nursing mothers of preterm infants
Ma. Corazon P. Estrella, M.D., Jacinto Bias V. Man taring III, M.D., Grace Z. David, M.D.,
Michelle A. Taup, M.D.*

nutritional needs imposed by the acceler-

ABSTRACT
ated growth rates of their infants. More
OBJECTIVES: To determine if there is a significant difference in the often than not, however, the biggest ob-
volume of breastmilk on postpartum days 3 to 5 among mothers with stacle to the initiation of feeding breast
,preterm infants who take malunggay (Moringa oleifera) leaves com- milk is collection. Most mothers after initi-
pared to those who were given placebo. ating expression of breastmilk on the first
SETTING: Tertiary government hospital few days after birth complain of insuffi-
STUDY DESIGN: Double-blind, randomized controlled trial cient volume ofbreastmilk. This complaint
PATIENTS AND METHODS: A total of 68 postpartum mothers admit- has prompted most mothers to use milk
ted at a tertiary government hospital and whose infants had pediatric formula, shift to bottle feeding, and dis-
ages of less than 37 weeks and admitted to the NICU for tube feedings continue breastfecding.
were included in the study. The mothers were randomized to receive
Moringa oleifera(encapsulated in a commercial preparation contain- Little quantitative data are available
ing 250 mg of leaves) or an identical capsule containing flour as pla- with which to evaluate protocols for the
cebo. They were asked to pump their breasts using a standardized initiation and maintenance of successful
breastpump from day 1 to day 5 postpartum. The mothers were given lactation during the long periods of infant-
capsules on postpartum days 3 to 5 . The contents Of the capsules mother separation that commonly follow
were unknown to both Investigator and subjects. T-test was used to premature delivery. De Carvalho, et al
determine differences in baseline variables. Chi-square was used to ( 19'85) 1 reported that the frequency of milk
determine difference in baseline proportions between groups. One- expression was associated positively with
way ANOVA was used to determine if there were significant differences milk production in mothers of premature
in the volume of breastmilk between treatment and control groups. A infants, but the mean volumes of milk pro-
p-value of <0.05 was considered significant. duced by women in that study did not meet
RESULTS: There was a trend towards increased milk production among the nutrient needs of VLBW infants and
those on Moringa oleifera leaves (Day 3: 114.1 ml ± 62.9 vs. 87.2 ± declined production are common problems
49.1; Day 4: 190 ml ± 103.5 vs. 128.8 ± 84.9; Day 5: 319.7 ml ± 154.10 associated with premature delivery.
vs. 120.2 ± 54.7). This was statistically significant on Day 4 (p 0.007) =
and on Day 5 (p = 0.000). A pilot study was done by the au-
CONCLUSION: Moringa oleifera leaves increase milk production on thors among 10 mothers who delivered
postpartum days 4 to 5 among mothers who delivered preterm in- neonates whose pediatric ages were less
fants. than 37 weeks in a tertiary government
KEYWORDS: breastmilk, malunggay hospital. The total amount of volume of
breastmilk expressed for 24 hours was plot-
Feeding breastmilk to premature in- duced by women who deliver prematurely ted from Day 1 to Day 7. Results showed
fants is of interest because of its potential is more appropriate for VLBW infants than that there was a steady increase in milk
nutritional and immunologic benefits. The is donor milk from later stages of lactation, volume from days 1 to 3 after which a con-
prevailing consensus is that early milk pro- and that is to feed each infant milk pro- stant or lower volume was recovered from
duced by his/her mother minimizes poten- days 3 to 5. The authors determined that 3
tial risks from contaminants. To implement to 5 days postpartum is critical for the suc-
* From the Department of Pediatrics, UP- this consensus, mothers ofVLBW infants cess of implementing a breastfeeding pro-
PGH Medical Center must produce sufficient milk to meet the gram among mothers who deliver preterm

Vol. 49 No. 1 January-March 2000 golacta.com. Used with permission. 3

infants. 2
OBJECTIVES
This investigation is being undertaken
with the following objectives: to determine
the volume of breast milk that is expressed
on postpartum days 3 to 5 among mothers
who delivered prematurely who were given
mulunggay leaves compared to those who
were given placebo and to determine if
there is a significant difference in the vol-
ume of breast milk on postpartum days 3
to 5 between the two groups.
PATIENTS & METHODS
This is a double-blind randomized
controlled trial.
lated from post-partum days 3 to 5.
All data were entered using Microsoft
Excel 97. Statistical analysis was clone
using SPSS version 9.0 software.
T-test was used to determine differ-
ences in numeric baseline variables. Chi-
square was used to determine difference
in baseline proportions between groups.
One-way ANOVA was used to deter-
mine if there were significant differences
in the collected volume of breastmilk
among mothers on the study medication
compared to placebo. A p-value of <0.05
was considered significant.
RESULTS
There were 14 subjects who did not sub
mit their notebooks and who were consid
ered drop-outs, 9 from the treatment grOUJ
and 5 from the control group. There wen
11 mothers whose data were not complet1
because their infants expired before the 6tl
postpartum day. Thus, a total of 68 moth
ers were analyzed. Thirty-one (31) moth
ers were in the Treatment Group and 3 ~
mothers were in the Control Group.
There is no significant difference ir
the gravidity, maternal age, and infants
pediatric ages and infants' birthweights.
The mean volume of milk collectec
among the treatment groups from postpar·
tum days 3 to 5 are presented in Table ~
and Figures 1.

All mothers who delivered live infants A total of 82 mothers were recruited. On day 3, the Treatment Group had 2
Jess than 37 weeks and admitted to the
NICU for tube feedings were eligible for Table 1
inclusion into the study. Excluded were BASELINE CHARACTERISTICS OF TREATMENT AND
mothers with hypertension post-delivery, CONTROL GROUP
diabetes mellitus, chorioamnionitis, Baseline Characteristic Treatment Group Control Group p- value
chronic illness or taking any medication Maternal Age (years) 25.8 ± 5.1 30.9 ± 15.7 0.09
on a regular basis, breast anomalies, and Pediatric Age (weeks) 33.7 ± 1.9 33.1± 2.3 0.30
those with infants with congenital anoma-
Infant's Weight:(grams) 1,532.7 ± 361.5 1,424.6 ± 359.2 0.22
lies. After informed consent, mothers were
randomized using a table of random num- Median gravidity 2 3 0.32
bers. Randomization was done by a per-
son not involved in the study. Assign- Table2
ments were concealed using sealed opaque VOLUME OF BREASTMILK (in m1) ON PASTPARTUM DAYS 3 TO 5
OF TREATMENT AND CONTROL GROUPS
envelopes. Those assigned to the treat-
ment group were given Moringa oleifera Day Post-partum Treatment Group Control Group p- value
leaves in a commercial capsule preparation Day3 114.1+1-62.9 87.2+1-49.1 0.052
250 mg every 12 hours starting on the 3rd Day4 190.0+-103.5 123.8 +- 84.9 0.007
postpartum day. Those who were assigned
to the placebo group were given flour con- Day 5 319.7+-154.1 120.2+1-54.7 0.000
tained in identical capsules. Capsules were
Figure 1
prepared by a research assistant who was
VOLUME OF BREAST MILK COLLECTED FROM
not directly involved in the study. Treat- POST-PARTUM DAYS 3 TO 5
ment assignments were unknown to both
400
the investigators and study subjects.

After proper orientation, demonstra-

tion and training, mothers were then in- ~
g200
300

I
~I
structed to pump their breasts every 4
hours using a standardized breast pump. l3
~ INTERVENTION
Volume was measured using standardized ~
containers and recorded in standard note- {00 ::r:I I
.. Plaoollo
books provided by the study personnel. I
When available, the volume of milk col- o.J-.--,..,---:---:-:----::---::,.-::-
.. ___. o r -
lected was also measured by the study
personnel. Total milk volumes were tabu-
OAY

4 golacta.com. Used with permission.

The Philippine Journal of Pediatrics

mean breastmilkvolumeof 114.1 ± 62.9 m1
compared to the Control Group with a
mean of 87.2 ± 49.1 mi. This showed a
mean difference of20-30 ml or a 28-32%
increase in breast milk volume in favor of
treatment.
On day 4, the Treatment Group had a
higher mean breast milk volume of 190 ±
103.5 ml compared to the Control Group
with only 123.8 ± 84.9 ml. This showed a
mean difference of 54-77 ml or a 51.:.58 %
increase in favor of treatment.
On day 5, the difference was even big-
ger with the Treatment Group haviiig a
breast milk volume of319.7 ± 154.1 m1 com-
pared to the Control Group who had 120.2
± 54.7 mi. This had a mean difference of
154-245 ml or a 152-176% increase in
breast milk volume in favor of treatment.
There were no reported adverse ef-
fects in both groups. ·
DISCUSSION
Lactogenes.is is initiated in the post-
partum period by a fall in plasma proges-
terone in the presence of maintained prol-
actin concentrations. Initiation of the proc-
ess does not depend on suckling of the
infant although the rate of milk secretion
after the third or fourth day postpartum
declines if milk removal is not practiced at
regular intervals. 3 A foreign study 4 on milk
volume produced by women aged 20 to 38
years who delivered at 28 to 30 weeks ges-
tation showed that optimal milk produc-
tion was associated with five or more milk
expressions per day and pumping
durations that exceeded 100 minutes per
day.
After deli very, the basal levels of pro-
lactin fall and, even in women who
breastfeed, they approach the normal
range by 2 to 3 weeks postpartum. 5 When
suckling occurs prolactin is promptly re-
leased, the levels rising 5 to 10 fold for
about 30 minutes. Tactile sensitivity of the
nipple, markedly reduced during preg-
nancy, increases within a few hours of de-
livery and is clearly geared to efficient suck-
ling.
~ Vol. 49 No. 1 January-March 2000
In the early puerperium, the amount
of milk produced correlates with the
amount of prolactin released during suck-
ling, significantly larger amounts of prol-
actin being released by "good" feeders
(over 700 ml of milk a day) than by "poor"
feeders, both the yield of milk and the
amount of prolactin released increases. 6
Many physiologic factors influence
milk composition and volume. These in-
clude premature delivery, age of the
mother, within-feed regulation of milk re-
lease, and the baby's demand for milk.'
There is little infonnation on milk volume
produced by mothers giving birth prema-
turely.1 Anecdotally, premature deliveries
have been associated with a decrease in
volume of breastmilk compared to term
deliveries because of the relative absence
of sucking stimulation among mothers of
preterm infants who cannot nurse because
of the long infant-mother separation and
because their infants may be too small to
suckle directly.
Honnonal stimulation of the mammary
gland, such as occurs during nursing, is
an important regulator of amount of milk
produced. In the non-nursing mother,
breast stimulation by pump can also in-
duce prolactin release comparable with that
induced by suckling. 6 As long as sucking
stimulation continues, in this study, the
pumping action of a breast pump/reliever,
there is pr.oduction of large volumes of
milk. Conversely, if there is a decrease in
blood flow, as occurs in response to stress,
milk secretion declines because the mam-
mary supply of oxygen, glucose, fatty adds,
and amino adds is reduced.R Maternal
stress was not evaluated during the study,
although each family was experiencing
strain due to their infants' hospitalization.
Lactagogues or galactogues are spe-
cial foods, drinks, or herbs which people
believe can increase a mother's milk sup-
ply. In most parts of the Philippines, women
take malunggay (Moring a oleifera) leaves
mixed in chicken or shellfish soups to en-
hance breast milk production. The mecha-
nism of action has not been explained but
it was effective as a galactogogue and has
been used by generations of nursing llJOth-
ers especially those with inadequate lac-
golacta.com. Used with permission.
9
tation.
A local study done in 1996 by
Almirante and Lim demonstrated the lac-
tation-enhancing effect of malunggay
leaves as evidenced by a greater increase
in maternal serum prolactin levels and per-
centages of gains in the infants' weights
among the lactating mothers who took the
malunggay leaves. 10 This ca.n probably
explain its mechanism of actiQQ. A follow-
up study done by the same authors among
hypertensive mothers showed similar re-
sults, with significant increases of tin val-
ues in the treatment group (Moring a
oleifera group) compared to the placebo. 11
The authors in the same study recorded
the breastmilk volume of a subgroup of
mothers (eight out of 31 mothers) whom
they did direct measurements of expressed
milk on the first, second, and fourth month
postpartum. They recommenced adding
more subjects to this subgroup of moth-
ers to increase the level of significance. 11
So far, no study has demonstrated the
clinical effect of malunggay leaves on a
more clinically relevant outcome, that of
breast milk volume, particularly on moth-
ers of pretem1 infants.
Our current study demonstrated the
lactation-enhancing effect of malunggay
(Natalac capsules) leaves as evidenced by
the significantly greater increase in the
volume of milk expressed by mothers on
the 3rd to the 5th postpartum day given
Moringa oleifera capsules compared to
those given placebo. The increase in vol-
ume of breastmilk on the third day post-
partum only had a tendency to be signifi-
cant at p < 0.052. This may be due to the
fact that we only started giving the treat-
ment drug (Moringa oleifera capsules) on
this day. We recommend either giving the
treatment drug earlier, probably on post-
partum day 2 or increasing the sample size
to increase the level of significance for sta-
tistical analysis on day 3 postpartum.
CONCLUSION ·
We, conclude that Moringa oleifera
leaves increase the volume of breastmilk
produced by mothers of preterm infants
on post-partum days 3 to 5. We therefore
5
recommend its routine use among moth-
ers of preterm infants to augment lacta-
tion, thereby ensuring an adequate sup-
ply of breastmilk in the population that
needs it the most.
REFERENCES
1. De Carvalho M & Anderson DM. Fre-
quency of Milk Expression and Milk
Production by Mothers of Non-Nurs-
ing Premature Neonates. AJDC.
1985:139:483-85.
2. Estrella MCP & Man taring JB III. Vol-
ume ofBreastmilk Expressed by Non-
Nursing Mothers of Preterm infants
on the First Post-partum Week: A Pi-
lot Study. March 1999. (Unpublished)
View publication stats
golacta.com. Used with permission.
3. Woolridge MW & Greasely V. The
Initiation of Lactation: The Effect of
Early versus Delayed Contact for
Suckling on Milk Intake in the First
Week Postpartum. Early Human De-
velopment. 1985: 12:269-278.
4. Hopkinson JM & Schanier RJ. Milk
Production by Mothers of Premature
Infants. Pediatrics. 1988:81:815-20.
5. Neville MC. Regulation of Mammary
Development and lactation. Lactation,
Physiology, Nutrition, and
Breastfeeding. New York: Plenum
Press, 1983: 103-40.
6. Aono T, Sihoji T, Shoda T, & Kurach
K. The Initiation of Human Lactation
and Prolactin Response to Suckling.
Journal of Clinical Endocrinology and
Metabolism,44, 1101.
7. Anderson GH. Human Milk Feeding.
Pediatric Clinics of North America.
1985: 32 (2): 335-53.
8. Tucker HA. Endocrinology of Lacta-
tion. Seminars in Perinatology. 1979:
33: 199-223.
9. Department of Health, Philippines.
Helping Mothers to Breastfeed. Pub-
lished by UNICEF, 1991.
10. Alrnirante CY & Lim CHTN. Effective-
ness of natalac as a Galactogogue.
Journal of Philippine Medical Asso-
ciation. 1996: 71: 265-272.
11. Almirante CY & Lim CHTN. Enhance-
ment ofBreastfeeding Among Hyper-
tensive Mothers. Increasingly Safe
and Successful Pregnancies. 1996:
279-286.
Sulistiawati Y, et al. Belitung Nursing Journal. 2017 April;3(2):126-133
Accepted: 28 February 2017
http://belitungraya.org/BRP/index.php/bnj/

© 2017 Belitung Nursing Journal

This is an Open Access article distributed under the terms of the Creative Commons
Attribution 4.0 International License which permits unrestricted non-commercial use,
distribution, and reproduction in any medium, provided the original work is properly cited

ORIGINAL RESEARCH ISSN: 2477-4073

EFFECT OF MORINGA OLEIFERA ON LEVEL OF PROLACTIN

AND BREAST MILK PRODUCTION IN POSTPARTUM MOTHERS
Yuni Sulistiawati1,2*, Ari Suwondo3, Triana Sri Hardjanti4, Ariawan Soejoenoes1, M. Choiroel
Anwar1, Kun Aristiati Susiloretni1

1
Magister Applied Midwifery, Health Ministry Polytechnic Semarang, Semarang, Indonesia
2
Akademi Kebidanan Patriot Bangsa Husada Lampung, Indonesia
3
Jurusan Kesehatan dan Keselamatan Kerja, Fakultas Kesehatan Masyarakat, Universitas Diponegoro,
Semarang, Indonesia
4
Prodi D4 Kebidanan, Health Ministry Polytechnic Semarang, Semarang, Indonesia

*Correspondence:
Yuni Sulistiawati, S.ST
Magister Applied Midwifery, Health Ministry Polytechnic Semarang
Jl. Tirto Agung, Pedalangan, Banyumanik, Kota Semarang, Jawa Tengah, Indonesia (50268).
E-mail: ysulistiawati80@gmail.com
ABSTRACT
Background: Breastfeeding among postpartum mothers has been a problem due to low milk supply. As a result,
mothers often decide to give formula milk or other additional foods, which might affect to the infant’s growth
and development.
Objective: This study aims to investigate the effect of Moringa Oliefera on the levels of prolactin and breast
milk production (baby’s weight and sleep duration) in postpartum mothers.
Methods: Quasi-Experimental study with Non Equivalent control group design. There were 30 respondents
recruited by purposive sampling, consisted of 15 respondents in intervention group and 15 respondents in the
control group. This study was conducted from November until December 2016 in Four Midwive Independent
Practice (BPM) in the working area of the Health Center of Tlogosari wetan Semarang. Data were analyzed
using Independent t-test.
Results: Findings showed that there was a mean difference of prolactin level in the intervention group (231.72
ng / ml), and the control group (152.75 ng / ml); and a significant effect on increasing the levels of prolactin (p =
0.002). The mean of baby’s weight in the intervention group was 3783.33 grams, and in the control group was
3599.00 grams. However, there was no significant effect of moringa oleifera on baby’s weight (p = 0.313>
0.05). While the mean difference on sleep duration was 128.20 minutes in the intervention group and 108.80
minutes in the control group. There was a significant effect on baby’s sleep duration (p= 0.000).
Conclusion: There were significant effects of moringa oleifera on mother’s prolactin and sleep duration of the
baby. However, there was no significant effect on baby’s weight. Thus, it can be suggested that moringa oleifera
can be used as an alternative treatment to increase breast milk production and prolactin hormones. Midwives
should promote the benefits of moringa leaves as one of alternative supplements.

Key words: breast milk production, pospartum, prolactin, moringa oleifera

  Belitung Nursing Journal , Volume 3, Issue 2, March-April 2017 126

INTRODUCTION
As a global public health
recommendation, infants should be
exclusively breastfed for the first six
months of life to achieve optimal growth,
development and health.1 Breast milk has
proved having immunological factors and
bioavailability, and increases intelligence
if compared to milk formula.2 Various
studies show that breastfeeding is
beneficial in terms of health and
socioeconomic, increases cognitive
development, and improves infant
survival, including to reduce the rate of
infant morbidity and mortality caused by
tract infections. While for the benefits for
mother, breastfeeding lowers the risk of
postpartum hemorrage and breast cancer,
and delays pregnant.3,4
Breast milk as the best food for
infants is not in doubt. But in fact, low
rates of breastfeeding have been identified
in Indonesia due to low milk supply or
production in mothers.5 As a result,
mothers decided to give formula milk or
other additional foods, which might affect
to the growth of the baby.
There are several factors influencing
breast milk production according to the
literature, such as breast anatomical and
physiological factors, psychological
factors, baby sucking factors, nutritional
factors, drugs or ingredients from plants.6
Additionally, prolactin and oxytocin
hormones also play role in increasing milk
production, which prolactin affects the
amount of milk production, while
oxytocin affects the secretion process.7
In line with this, medical
intervention that is usually given to
mothers to help breast milk production is
by giving Metoclopramide (Reglan) in
long-term use and oxytocin nasal.
However, these might have side effects,
for instance, metoclopramide can cause
depression in mothers, and a spray of
oxytocin nasal (Syntocinon, one spray in
each nostril, two minutes before feeding)
127
  Belitung Nursing Journal , Volume 3, Issue 2, March-April 2017
make mothers feel headache. Therefore, in
regards to those side effect, alternative
intervention is needed.8
Indonesa is one country that is rich
in various types of medicinal plants that
have been proven scientifically. Some of
them that can increase the breast milk
production are katuk or star gooseberry,
lampes, adas manis, bayam duri, bidara
upas, blustru, dadap ayam, jinten hitam
pait, nangka, patikan kebo, pulai, ginger,
turi, papaya and moringa.9 However, this
study only focuses on moringa oleifera.
Moringa plants in Indonesia is a
local grocery that has the potential to be
developed into a culinary of breastfeeding
mothers, compounds contain phytosterols
(included in the steroid classification),
which works to improve and expedite the
production of milk (laktogogum effect).10
Its effect on breast milk production has
been proven in previous studies.11,12
However, little is know about its effect in
the setting of this study, in the working
area of the Health Center of Tlogosari
Wetan. The effort of midwives to deal
with low breast milk production, based on
preliminary study, was just limited to the
health education. Therefore, this study
aims to examine the effect of moringa
oleifera on breastmilk production and
prolactin level in postpartum mothers.
METHODS
Design
This study was quasi-experimental study
with pretest postetst with control group.
Setting
This study was conducted from November
until December 2016 in the Four Midwive
Independent Practice (BPM) in the
working area of the Health Center
(Puskesmas) of Tlogosari Wetan
Semarang. Two BPMs for the intervention
group and the other two BPMs for the
control group. These 4 BPMs were in
different area to avoid reaction effect from
respondents.
Target Population and Sample
Target population in this study was
normal postpartum mothers who gave
birth in BPM in Puskesmas Tlogosari
Wetan Semarang. There were 30
respondents recruited by purposive
sampling, which consisted of 15
respondents in intervention group and 15
respondents in the control group. The
inclusion criteria of the samples were
postpartum mothers in the 1st day until
the 15th day, willing to breastfeed
exclusively, not taking herbs or any
breastfeeding supplements, willing to be
respondents, aged 20-35 years old; and the
baby's weight ranged from 2500-4000
grams. The exclusion criteria included:
post partum mother with abnormal breast
nipple, chronic energy deficiency (upper
arm circumference <23.5 cm), babies with
abnormalities (cleft lip), and postpartum
mothers with complications (bleeding,
infection).
Intervention
The intervention group was given moringa
oleifera leaves in the form of capsule,
which consisted of 28 capsules for each
respondent. This capsule was taken two
times per day at 7.30 am and 4 pm. There
was no side effects if taken outside these
hours, but just to facilitate respondents in
a given time consumption of the capsules
and facilitate monitoring of infant sleep
duration after feeding. The dose of each
capsule was 250 mg and was taken 30
minutes before breastfeeding. This
capsule was given since the first day of
postpartum until the 14th day. While the
control group was just given the
midwifery care based on standard, namely
health education about breastcare and
newborn care, and given vitamin and Fe
tablet.
  Belitung Nursing Journal , Volume 3, Issue 2, March-April 2017
Instruments
Researchers conducted blood sampling as
much as 3 cc on the first day after delivery
in the control and the treatment group
before the intervention, then separated
between plasma and serum using
centrifuges by lab personnel of GAKI
UNDIP; and the second blood sampling
was conducted on 15th day of postpartum
in the intervention and control group after
intervention. While prolactin hormone
level measurement was performed in the
laboratorium of GAKI UNDIP using
Microplate Reader. In this study, the
weight of infant was also measured to see
the successful of breastfeeding of the
mothers giving their milk to the babies. It
was performed three times, namely the 1st
day, 7th day, and 14th day, using digital
scales that had previously been calibrated
with number ARN-EBSD-01. In addition,
the duration of baby’s sleep was also
observed after feeding as another indicator
of breast milk production, and noted in the
observation sheet in the morning and
evening for 14 days.
Ethical consideration
This experiment received study
permission from the Health Research
Ethics Committee of the Health Ministry
Polytechnic Semarang with number: 174 /
KEPK / polytechnic-smg /EC / 2016.
Data Analysis
Data were analyzed using univariate and
bivariate analysis. Independent t-test was
performed for this study.
RESULTS
Table 1 showed that there were changes in
prolactin level, baby’s weight and sleep
duration. It could be seen from the result
of posttest of prolactin level, which was
231.72 % in the intervention group and
152.39 % in the control group. The
increase in baby’s weight also occurred in
128
the intervention group (3783.33) intervention group (128.20) was longer
compared with it (3599.00) in the control than the baby’s sleep duration in the
group; and sleep duration in the control group (108.80).

Table 1. Prolactine hormon and breast milk production (baby’s weight and sleep duration)
before and after intervention in the intervention and control group

Variable n Mean SD Min Max

Prolactine Level
Intervention (Pre) 15 92.11 460.47 34.91 167.05
Control (pre) 15 97.82 596.14 38.46 208.73
Intervention (post) 15 231.72 604.45 127.88 312.59
Control (post) 15 152.39 678.67 63.67 284.98
Breast Milk Production
Weight (1st day)
Intervention 15 3256.67 399.05 2500 4100
Control 15 3366.67 343.03 2700 4300
Weight (7th day)
Intervention 15 3503.33 469.98 2700 4200
Control 15 3383.33 521.22 2700 4300
Weight (15th day)
Intervention 15 3783.33 460.07 3100 4500
Control 15 3599.00 520.19 2950 4500
Sleep duration
Intervention 15 128.20 5.467 114 135
Control 15 108.80 6.742 98 119

Table 2. Effect of Moringa Oleifera on changes in prolactin hormone and breast milk
production after intervantion in the intervention and control groups
Variable n Mean SD SE p-value
Prolactin level
Intervention 15 231.72 60.45 15.61 0.002
Group 15 152.75 66.99 17.29
Breast milk production
Weight (15th day)
Intervention 15 3783.33 460.07 118.79 0.313
Control 15 3599.00 520.19 134.32
Sleep duration
Intervention 15 128.20 5.47 1.41 0.000
Control 15 108.80 6.74 1.74

The results of independent t-test in the
table 2 showed that the mean of prolactin
level in the intervention group was 231.72
ng/ml with a standard deviation of 60.45
ng/ml, and the mean in the control group
was 152.75 ng/ml with a standard
deviation 66.99. The result showed that
there was a significant effect on
increasing the levels of prolactin with
significant value of p = 0.002 <0.05 with
α = 5%.
The result also showed that the
mean of baby’s weight in the intervention
group was 3783.33 grams with a standard
deviation of 460.07 grams, and in the
control group was 3599.00 grams with a
standard deviation of 520.19 grams.
However, there was no significant effect

129   Belitung Nursing Journal , Volume 3, Issue 2, March-April 2017

of moringa oleifera on baby’s weight with
significant value of p = 0.313> 0.05 with
α = 5%.
While the mean of sleep duration in
the intervention group was 128.20
minutes with a standard deviation of 5.467
minutes, and the control group had the
mean of sleep duration of 108.80 minutes
with a standard deviation of 6.742
minutes. The mean difference between the
intervention and control groups was 19.4
minutes. The statistical result showed the
p-value of 0,000, which indicated that
there was a significant effect of Moringa
oleifera on baby’s sleep duration.
DISCUSSION
Effect of Moringa Oleifera on prolactin
level
An amount of breast milk in the early
postpartum is correlated with the amount
of prolactin released during breastfeeding
after birth.13 The main stimulus that
maintains prolactin secretion is sucking,
which milk production will continue as
long as the baby continues to suck breast
milk.13 When mothers breastfeed their
babies, nerve signals from the nipple to
the hypothalamus will cause a surge of
prolactin secretion about 10 to 20 times
for approximately 1 hour. Prolactin is
working on the breast to keep the glands
of mammals that secrete milk into the
alveoli to the next lactation production.14
This is supported by research that
prolactin levels are different in each
periode. The results of research conducted
in sixteen breastfeeding mothers found
that the serum levels of prolactin were
different between groups of breastfeeding
mothers at the first week, fourth weeks,
and eighth weeks of postpartum, at the
first menstrual period after birth and after
the babies done weaning.15 It showed that
the prolactin levels in the fourth weeks of
post partum were higher compared with
the others.15
  Belitung Nursing Journal , Volume 3, Issue 2, March-April 2017
In this study, findings showed that
the levels of prolactin in the intervention
group was higher than them in the control
group. It is because the capsules of
Moringa leaves contain chemical
compounds of phytosterol (poliferol and
sterols), which the compound plays a role
to increase prolactin levels. 10 High
prolactin levels have a function to
improve, accelerate, and facilitate milk
production.16
In addition, phytosterols and
steroids contained in Moringa leaves have
the power effect of lactagogue, which can
occur by: stimulating directly the
activities of protoplasm of cells secretory
of mammary gland, stimulating the
secretory nerve endings in the milk glands
so that secretion milk increased, or
stimulating the hormone prolactin, which
is working on alveolar epithelial cells. 10,17
Prolactin or luteotropin (LTH) is a
lactagogue hormone and proliferative
against the mammary gland. Effects of
prolactin in humans or mammals is the
stimulation of lactation.18 Additionally,
lactagogue function can also improve
glucose metabolism for lactose synthesis
that increases milk production.18
The finding of this study was also in
line with the research results indicated
that the galactogague of Moringa oleifera
has been an induction of prolactin
production in the anterior pituitary gland.
Study reported that patients with the
Moringa has a higher level of prolactin
level with an average of a statistically
significant increase of 19.5 • 102 mIU /
L.10
Effect of Moringa Oleifera on breast milk
production
Based on literature review, indicators of
an assessment of the breast milk
production could use some criteria as a
reference to determine the secretion of
breast milk and the amount sufficient for
the baby, such as an increase in infant
130
weight, frequency and urine color,
frequency and characteristics of
defecation, sleep duration or baby
calmness after feeding.14
In this study, breast milk production
was measured based on the indicator of
baby’s weight and sleep duration. The
findings of this study indicated that there
were mean differences of baby’s weights
between the intervention and control
groups in the 1st day, 7th day, and 15th day
of treatments. However, there was no
significant difference of moringa oleifera
on baby’s weight with significant value of
p = 0.313> 0.05 with α = 5%. It was
because the slight difference of mean of
baby’s weight between two groups. Yet, it
could be explained that the number of
breast milk production by the mothers
might not be sufficient for the baby. This
finding was in line with research
conducted by orphan y who examined the
influence of extract of Moringa leaves on
birth weight and length birth weight of
babies in pregnant women for 3 months,
and it showed that no significant
difference in mean birth weight ( p =
0.168) and the length of infant birth
weight (p = 0.612).19 Thus, it could be
said that the process of breast milk
production is not that easy, which is
influenced by two hormone, namely
prolactin and oxytocin hormones.
Breast milk production is influenced
by the hormone prolactin, which is
continuously secreted into alveoli of the
breast, but the milk does not flow easily
from the alveoli into the duct system so
that the milk does not drip continuously in
the nipple. To drain the milk from the
alveoli into the duct requires a process of
merging neurologic and hormonal reflex
involving the posterior pituitary hormone,
namely oxytocin. If this hormone do not
work then the baby will not get enough
breast milk.14,20,21
Oxytocin reflex is more complicated
than prolactin reflex. Thoughts, feelings
131
  Belitung Nursing Journal , Volume 3, Issue 2, March-April 2017
and sensations mother will greatly affect
this reflex. Maternal feelings can increase
and inhibit oxytocin. If stress happens,
then the hormone refelx will be blocked
from Let-Dwon reflex.14 It is due to the
release of adrenaline epinephrine which
causes vasoconstriction of blood vessels
of alveoli, so that the oxytocin hormone
can not reach the target organ, namely
mioepitelhelium. 14 As a result of
incomplete Let-Dwon reflex, there will be
a buildup of milk in alveoli, and baby will
not get enough milk, while the amount of
the volume of milk can affect the baby's
weight. 14 In addition, the speed of the
baby's body fluid exchange is 7 times
greater than in adults. 14
On the other hand, breast milk flow
is not in the same time. The content of
breast milk flow in the first minute and
the last minute of baby sucking is quite
different. Protein and fat are much higher
in the last minutes of breastfeeding than in
the first few minutes; or it could be said as
‘Foremilk’, the milk which is first drawn
during a feeding. It is generally thin and
lower in fat content, satisfying the baby’s
thirst and liquid needs; and also
‘Hindmilk’, the milk which follows
foremilk during a feeding. It is richer in
fat content and is high in calories. The
high fat and calorie content of this milk is
important for your baby’s health and
continuing growth.22
The findings of this study also
revealed that there was a significant effect
of Moringa oleifera on baby’s sleep
duration. The mean of sleep duration in
the intervention group was 128.20
minutes with a standard deviation of 5.467
minutes, and the control group had the
mean of sleep duration of 108.80 minutes
with a standard deviation of 6.742
minutes. The mean difference between the
intervention and control groups was 19.4
minutes. This result could be assumed that
the babies in the intervention group had
all of the benefits of breast milk.
However, although the results showed the
significant effect, it cannot be mentioned
that the breast milk production was good 3.
enough, because it should have 4 of 7
indicators that should be observed. In
addition, sleep duration of each baby
might not be the same because each
individual is unique.
4.
LIMITATION OF THIS STUDY
The limitation of this study included that
phsycological changes in mothers were
not observed by researcher in detail.
Although researchers had tried to control
this factor by asking and providing
support to the respondents during the 5.
research process, but it can not be denied
if the respondents still felt worried and did
not tell the researcher.
CONCLUSION 6.
Based on the results of this stduy, it could
be concluded that there were significant
effects of moringa oleifera on mother’s 7.
prolactin and sleep duration of the baby.
However, there was no significant effect
on baby’s weight. Thus, it can be
suggested that the capsules of moringa 8.
oleifera can be used as an alternative
treatment to help mothers in breast milk 9.
production and increase their prolactin
hormones. Midwives should promote the
benefits of moringa leaves as one of
alternative supplements. Further study is
needed to observe all indicators of breast 10.
milk production, not just limited to the
baby’s weight and sleep duration.
REFERENCES 11.
1. WHO. The World Health
Organization's infant feeding
recommendation. 2001;
http://www.who.int/nutrition/topics/
infantfeeding_recommendation/en/.
Accessed 12 March, 2017. 12.
2. Hacker NF, Gambone JC, Hobel CJ.
Hacker and Moore's essentials of
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obstetrics and gynecology: Elsevier
Health Sciences; 2015.
Kramer MS, Aboud F, Mironova E,
et al. Breastfeeding and child
cognitive development: new
evidence from a large randomized
trial. Archives of general psychiatry.
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Fewtrell MS, Morgan JB, Duggan
C, et al. Optimal duration of
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evidence to support current
recommendations? The American
journal of clinical nutrition.
2007;85(2):635S-638S.
Shetty P. Indonesia's breastfeeding
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World Health Organization. Bulletin
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Ladewig PW. Buku Saku Asuhan
Ibu dan Bayi Baru Lahir: Jakarta:
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Gabbe SG, Niebyl JR, Simpson JL,
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Constance S. A Midwife's
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Batugal PA, Kanniah J, Sy L, Oliver
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Raguindin PFN, Dans LF, King JF.
Moringa oleifera as a Galactagogue.
Breastfeeding Medicine.
2014;9(6):323-324.
Kiranawati TM, Nurjanah N.
Improvement of Noodles Recipe for
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Technology. 2014;2(3):88-92.
Titi MK, Harijono ET, Endang SW.
Effect lactagogue moringa leaves
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13. Uvnäs-Moberg K, Widström A-M,
Werner S, Matthiesen A-S, Winberg
J. Oxytocin and Prolactin Levels in
Breast-Feeding Women. Correlation
with milk Yield and Duration of
Breast-feeding. Acta Obstetricia et
Gynecologica Scandinavica.
1990/01/01 1990;69(4):301-306.
14. Guyton AC. Human physiology and
mechanisms of disease: WB
Saunders Co; 1992.
15. Tay CC, Glasier AF, McNeilly AS.
Twenty-four hour patterns of
prolactin secretion during lactation
and the relationship to suckling and
the resumption of fertility in breast-
feeding women. Human
reproduction (Oxford, England).
May 1996;11(5):950-955.
16. Farah Rizki SG. The Miracle of
Vegetables: AgroMedia; 2013.
17. Kumalasari R, Arimbi D,
Ismunandar A. PEMBERIAN
JAMU UYUP –UYUP
TERHADAP KELANCARAN
PENGELUARAN AIR SUSU IBU
(ASI) PADA IBU NIFAS. Paper
presented at: Prosiding seminar
nasional & internasional2014.
18. Sari IP. Daya Laktagogum Jamu
Uyup-uyup dan Ekstrak Daun Katu
(Sauropus androgynus Merr.) pada
Glandula Ingluvica Merpati:
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(traditional medicine) and Sauropus
androgynus Merr extract on pigeon
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inglu. Majalah Farmasi Indonesia.
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INFLUENCE OF MORINGGA
LEAF EXTRACT ON THE BORN
BABY’S WEIGHT AND LENGTH
FROM THE INFORMAL
SECTOR WORKING PREGNANT
WOMEN: Bagian Gizi, fakultas
Kesehatan Masyarakat, Universitas
Hasanuddin.
20. Biancuzzo M. Breastfeeding the
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Neonatal Nursing. 1999;13(1):92-
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21. Marshall JE, Raynor MD. Myles'
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22. Jay E. Where does fore-milk end
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does-it-actually-matter/. Accessed
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08/12/23 14.45 The effect of Moringa oleifera capsule in increasing breast milk volume in early postpartum patients: A double-blind, randomize…

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Eur J Obstet Gynecol Reprod Biol X. 2022 Dec; 16: 100171. PMCID: PMC9684698
Published online 2022 Nov 17. doi: 10.1016/j.eurox.2022.100171 PMID: 36440058

The effect of Moringa oleifera capsule in increasing breast milk volume in early
postpartum patients: A double-blind, randomized controlled trial
Siraphat Fungtammasan and Vorapong Phupong⁎

Abstract

Objectives

Moringa oleifera is an herbal galactagogue that is used to increase the volume of breast milk.
The objective of this study was to evaluate the efficacy of Moringa oleifera leaves in increasing
the volume of breast milk in early postpartum mothers.

Methods

A randomized, double-blinded, placebo-controlled trial was conducted. Eighty-eight postpar‐

tum women were randomized to either the study group receiving oral Moringa oleifera cap‐
sules or to the control group receiving oral placebo capsules.

Results

There was no difference in median breast milk volume on the third day of postpartum between
the Moringa oleifera leaf group and the control group (73.5 vs 50 ml, p = 0.19). However, the
amount of breast milk in the Moringa oleifera group was 47% more than the one in the control
group. The exclusive breastfeeding rate at 6 months in this study was 52.3% in the Moringa
oleifera group, which met the goals set by the World Health Organization.

Conclusions

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9684698/ 1/10
08/12/23 14.45 The effect of Moringa oleifera capsule in increasing breast milk volume in early postpartum patients: A double-blind, randomize…

Even 900 mg/day of the Moringa oleifera leaf could not significantly increase breast milk vol‐
ume in early postpartum mothers, but the amount of breast milk in the Moringa oleifera group
was 47% more than the one in the control group. The exclusive breastfeeding rate at 6 months
in the Moringa oleifera group achieved the goals set by the WHO. Therefore, Moringa oleifera
leaf may be used as a galactagogue herb to increase the volume of breast milk.

Keywords: Breast milk volume, Breastfeeding, Moringa oleifera, Postpartum

1. Introduction

Breast milk is the best food for babies. It is safe and clean, and contains antibodies that protect
them against common illnesses. It also contains helpful nutrients and energy for babies, espe‐
cially in the first month of life. Breastfeeding provides physiological and health benefits for
both the mother and the baby. The World Health Organization (WHO) and the United Nations
International Children's Emergency Fund (UNICEF) recommend that the baby be breastfed
within the first hour and exclusively for the first 6 months of life. WHO actively promotes
breastfeeding as the best source of nourishment for infants and young children, and has set
the rate of exclusive breastfeeding for the first 6 months up to at least 50% by the year 2025
[1].

Adequate volume of breast milk is the key factor for success in exclusive breastfeeding. Various
methods have been used to increase the volume of breast milk. The Cochrane database sys‐
temic review of 2020 demonstrated that natural milk boosters may improve milk volume and
infants' weight, but the review lacks adequate supporting evidence. This, therefore, requires
that more thorough studies be carried out to reliably certify the effects of milk boosters [2].
Galactagogue herbs, of which Moringa oleifera is one, have been used by breastfeeding moth‐
ers who have breast milk problems to increase the volume of breast milk [3]. Moringa oleifera
is widely used in traditional medicine. And the leaves together with the immature seed pods
are used as food products [4]. Moringa oleifera leaves increases the volume of breast milk by
increasing prolactin and providing essential nutrients [2], [5]. It takes about 24 h after inges‐
tion for the Moringa oleifera to work [6], [7]. Various safety studies were conducted on ani‐
mals using aqueous leaf extracts and the results indicated that there was a high degree of
safety. No adverse effects were reported in human studies [4]. However, few studies have eval‐
uated Moringa oleifera in breastfeeding. One study found that the consumption of Moringa
cookies increased the quality of breast milk, especially the amount of protein [8]. Another
study found that Moringa oleifera leaves increased the production of breast milk on postpar‐
tum days 4 and 5 among mothers who delivered preterm infants [7]. Also, it was discovered in
a study that women who took Moringa oleifera capsules had more breast milk per day from
postpartum days 3–10 compared to those women who were on placebos. However, this was
not statistically significant [6]. Thus, the objective of this study was to evaluate the efficacy of
Moringa oleifera leaves in increasing the volume of breast milk in early postpartum mothers.

2. Materials and methods

This randomized, double-blinded, placebo-controlled trial was performed at the Department of

Obstetrics and Gynecology, King Chulalongkorn Memorial Hospital, Faculty of Medicine,
Chulalongkorn University, Bangkok, Thailand. It is a baby-friendly hospital. The study was ap‐
proved by the Research Ethics Committee of the Faculty of Medicine, Chulalongkorn University
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08/12/23 14.45 The effect of Moringa oleifera capsule in increasing breast milk volume in early postpartum patients: A double-blind, randomize…

(IRB No. 157/63) and performed in accordance with the approved guidelines of the Research
Ethics Committee. Written informed consent was obtained from all participants. This clinical
trial was registered at ClinicalTrials.gov (Clinical trials registration: NCT04487613). The au‐
thors confirmed that all ongoing and related trials for this drug were registered. The complete
date range for participant recruitment and follow-up was 1 year and 6 months (November 1,
2020 – April 30, 2022). This study protocol (version 3, dated 4 June 2020) was published in
PLoS One 2021 [9].

Pregnant women aged 18 years or more with a gestational age of 37 weeks or more who in‐
tended to breastfeed were recruited for the sutdy and consent was obtained before delivery.
Randomization was done after delivery. Women with an uncomplicated full-term delivery who
had accomplished similar antenatal breastfeeding promotion protocol were included.
Postpartum women with contraindication to breastfeeding such as HIV, those on chemothera‐
peutic drugs, on radioactive substances, those whose babies had galactosemia or needed pho‐
totherapy were excluded, as were postpartum women with unstable conditions (i.e., postpar‐
tum hemorrhage, sepsis), known allergy to Moringa oleifera, or women with insufficient glan‐
dular tissue or who had breast surgery, women with a history of infertility, women with hy‐
pothyroidism, women with twins or higher order births, premature infants and infants with
sucking problems or structural oral anomalies that can affect sucking (e.g. tongue tie, birth as‐
phyxia, clefts, etc.).

After the study was approved, eligible postpartum women who had given informed consent
were consecutive enrolled in the study. All women received the same postpartum care along
with breastfeeding support procedures. The research nurses confirmed that all of them cor‐
rectly nursed their infants. Breastfeeding was initiated immediately after delivery in all the
women. They were encouraged to breastfeed their baby as frequently as they desired or
whenever the baby became hungry. The babies were fed directly from the breasts and all the
women breastfed exclusive. If the baby showed signs of inadequate milk intake, and if supple‐
mental feeds were given, these were controlled for the analysis. The data about supplemental
feeds were recorded by asking the women.

The drugs and placebo were prepared before the study by a pharmacist who was not involved
in the study. The treatment capsule contained 450 mg of Moringa oleifera leaves. The placebo
capsule had no content.

The participants were randomized into two groups: the treatment or placebo groups. A ran‐
domization scheme was generated by a random number table using a block-of-four technique.
The co-investigator, who had no contact with the participants, generated the allocation se‐
quence before the study. To ensure randomization, each envelope was distributed in sequential
numerical order. Both the health care providers and the participants were masked to the treat‐
ment assignment.

The nurses enrolled the participants. For each participant who met the inclusion criteria, the
nurses selected a sequentially numbered opaque envelope which contained 6 capsules of
Moringa oleifera leaf powder or placebo (identical in size, shape, and color). The opaque en‐
velopes were sealed to ensure that the allocation sequence was secure. The treatment group
received Moringa oleifera leaves powder (450 mg per capsule) (Ouay Un Osoth, Thailand) and
the placebo group received no-drug capsules. All the women took 1 capsule of the Moringa
oleifera or placebo 2 times before meal for 3 days. Participants took their first capsule at the
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first 6 h of birth. Treatment assignment was not revealed until data collection was completed 6
months later. All women were admitted into the postpartum ward and discharged on the
fourth day postpartum. Hence, all of them received all their medications. The research nurses
captured the measured outcome, and 8 personnel were involved in this study. The dosage of
450 mg Moringa oleifera leaf powder was used in the study due to the recommendation from
Thai traditional medicine for galactagogue. This dosage is higher than what was used in previ‐
ous studies [6], [7].

The primary outcome was the volume of breast milk on the third day postpartum. Secondary
outcomes were time to noticeable breast fullness, maternal satisfaction, quality of life, side ef‐
fects, and exclusive breastfeeding rate at 6 months. The third day was used as the measure‐
ment time point because it represented the timing of stage II lactogenesis [6]. The weighing
method was used on the third day postpartum (48–72 h). The weighing procedure started
48 h after delivery in all the women. The nurse weighed the infant fully clothed before and af‐
ter each feeding using an electronic weight scale (Camry ER 7210, accurate to 5 g) for 24 h.
Babies were weighed each time they wanted to be fed, even if they wanted the breast every
20 min.

The volume of breast milk was evaluated. The sum of the weight difference in grams was con‐
verted into the volume of the breast milk in milliliter (1 g = 1 ml). This method is comparable to
the measurement of the volume of the breast milk based on the deuterium oxide dilution tech‐
nique from a previous study [10], [11], [12].

Time to noticeable breast fullness was defined as the mean time from birth to noticeable
breast fullness. The participants were asked if they noticed their breasts were full, which was
followed by ‘When did you feel breast fullness?.’.

The participants were asked satisfaction and quality of life questions on postpartum day 7 via
a phone interview. Satisfaction answer choices consisted of the following: very satisfied, satis‐
fied, neutral, unsatisfied, and very unsatisfied. Quality of life was assessed by WHOQoL-BREF
[13]. Side effects were recorded on postpartum day 3 by an interview and on postpartum day
7 via a phone interview. The exclusive breastfeeding rate and any breastfeeding at 6 months
were asked via a phone interview.

The sample size calculation was based upon the findings from a previous study [14]. A two-
tailed test was used. The average volume of breast milk on day 3 postpartum was
123.8 ± 84.9 ml. We expected a 30% increase in the volume of the breast milk. With adjust‐
ments for a withdrawal rate of 30%, a minimum of 44 women in each group were required to
detect a statistical difference (α = 0.05, β = 0.2) between the two groups. Therefore, a total of
88 women were used for this study.

A data monitoring committee (DMC) was not needed in this study due to the short duration of
the trial and known minimal risks. Interim analyses were not performed in this trial due to the
short duration of recruitment and no potentially serious outcomes. No adverse effects were
reported in human studies eventhough the risk, both its types and severity, and the harm were
monitored. Side effects (such as constipation, nausea/vomiting, diarrhea, heartburn, hypoten‐
sion, hypoglycemia) and serious adverse effects/reactions both in the mothers and especially
vulnerable newborns (such as neonatal hypoglycemia, and hypotension) were monitored.
Harm was monitored and reported to the Research Ethics Committee of the Faculty of
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Medicine, Chulalongkorn University. Auditing was performed every 3 months by research

nurses who were not involved in the study. Investigators planned to provide care for partici‐
pants’ healthcare needs that arose as a direct consequence of trial participation and pay com‐
pensation to those who suffered harm from it.

2.1. Statistical analysis

IBM SPSS version 22 (SPSS: An IBM Company, New York, USA) was used for statistical analysis.
A two-tailed test was used in this study. The Kolmogorov-Smirnov test was used to assess data
distribution before statistical analysis. The Chi-square test and Fisher’s exact test were used
for categorical variables such as percentage of satisfaction and side effects. An independent t-
test was used for parametric continuous variables such as the volume of breast milk. A Mann-
Whitney U test was used for nonparametric variables. A p-value < 0.05 was considered statisti‐
cally significant. Analysis of the trial was conducted by using intent-to-treat (ITT) analysis.

3. Results

Two hundred and ten women were assessed for eligibility, and 122 were excluded (Fig. 1).
Eighty-eight women were enrolled in the study. All the women were randomized into two
groups: 44 received Moringa oleifera capsules and 44 received a placebo. All the women com‐
pleted the study. Baseline characteristics, including maternal age, gravida, parity, body mass in‐
dex, total weight gain, vital signs, gestational age at the delivery, and route of delivery were sim‐
ilar between the two groups (Table 1).

Fig. 1

Study flow diagram.

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Table 1

Baseline characteristics.

Baseline characteristics Moringa oleifera Placebo group P

group (n = 44) value
(n = 44)

Maternal age (years) 32.8 ± 5.7 33.18 ± 5.4 0.74

Gravida 0.82

Primigravida 15 (34.1%) 16 (36.3%)

Multigravida 29 (65.9%) 28 (63.6%)

Parity 0.39

Primiparity 20 (45%) 24 (54%)

Multiparities 24 (54%) 20 (45%)

BMI (kgs/m2) 23.47 ± 4 23.68 ± 4.3 0.82

Total weight gain (kgs) 14.28 ± 5.8 12.52 ± 5.6 0.15

Vital signs 109.54 ± 12.7 109.79 ± 21.4 0.95

SBP (mmHg) 64.79 ± 10.1 64.39 ± 8.8 0.84
DBP (mmHg) 83.57 ± 13.1 83.18 ± 12.4 0.89
Pulse rate (beats/minute) 36.87 ± 0.4 36.89 ± 0.5 0.32
Body temperature (°C)

GA at delivery (weeks) 38.64 ± 1.1 38.54 ± 0.9 0.62

Route of delivery 2 (5%) 4 (10%) 0.39

• Vaginal route 42 (95%) 40 (90%)
• Cesarean section

Labor medication

• spinal bupivacaine 41 (93%) 40 (90%) 0.82

• spinal morphine 41 (93%) 40 (90%) 0.12
• xylocaine 2 (4.5%) 3 (6.8%) 0.27

Amount of intravenous fluid (ml) 3000 3000 NA

Baby gender 22 (50%) 20 (45%) 0.67

Male 22 (50%) 24 (55%)
Female

Birth weight (grams) 3143.2 ± 467.5 3180.2 ± 382.2 0.69

APGAR score at 1 min 8.98 ± 0.1 8.86 ± 0.5 0.16

APGAR score at 5 min 9.95 ± 0.2 9.91 ± 0.3 0.40

Supplemental feeds 14 (31.8%) 20 (45.5%) 0.19

Do you think you got the placebo or the 22 (50%) 25 (56.8%) 0.27

Data presented as mean + SD, n (%) or median (interquartile range)

BMI: body mass index, SBP: systolic blood pressure, DBP: diastolic blood pressure, GA: gestational age

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The amount of breast milk volume on the third day postpartum was not different in the
Moringa oleifera and the placebo groups (median 73.5 ml vs 50 ml, p = 0.19) (Table 2).
However, the amount of breast milk in the Moringa oleifera group was 47% more than the one
in the control group.

Table 2

Breast milk volume, satisfaction, quality of life and side effects.

Result Moringa oleifera Placebo group (n P

group = 44) value
(n = 44)

Breast milk volume (ml)

Day 3 73.5 (35.7–138.7) 50 (26.3–126.5) 0.19

Participants noticed their breasts were full 41 (93.2%) 37 (84.1%) 0.18

When did participants feel breast fullness? (hours 52.5 (47–65) 54 (42–69.7) 0.18
after delivery)

Satisfaction 4 (4–5) 4 (3–5) 0.83

Quality of life 49.9 ± 6.3 48 ± 5.3 0.12

Side effect 0 0 NA
• constipation 2 (4.5%) 0 0.15
• nausea/vomiting 0 0 NA
• diarrhea 0 0 NA
• heartburn 1 (2.3%) 0 0.31
• hypotension 0 0 NA
• hypoglycemia 0 0 NA
• others 0 0 NA
1 (2.3%) 0 0.32

newborn 0 0 NA

• hypotension
• hypoglycemia
• others

Exclusive breast feeding at 6 months postpartum 23 (52.3%) 20 (45.5%) 0.52

Data presented as mean + SD or n (%) or median (interquartile range)

About the secondary outcomes, which included time to noticeable breast fullness, maternal
satisfaction, quality of life, and exclusive breastfeeding rate at 6 months, the results were not
different between two groups. However, the exclusive breastfeeding rate at 6 months in the
Moringa oleifera group met the goals set by the WHO (the rate of exclusive breastfeeding for
the first 6 months up to at least 50% by the year 2025); it did not meet the goals in the placebo
group.

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In terms of side effects, none were detected among participants and newborns in both groups.

4. Discussion

This randomized, double-blind, placebo-controlled trial evaluated the efficacy of the Moringa
oleifera leaf capsule to increase breast milk volume in early postpartum patients (day 3 post‐
partum). The result showed that the amounts of breast milk in the Moringa oleifera group and
control group were not significantly different. Even Moringa oleifera leaf could not significantly
increase the amount of breast milk on the third day postpartum, but the amount of breast milk
in the Moringa oleifera group was 47% more than what was in the control group.

The result of this study was different from the previous study by Estrella et al. [7]. They found
that Moringa oleifera leaves increased breast milk volume on postpartum days 4 and 5 in
mothers of preterm infants. This difference might be due to the different ethnic groups and
gestational age at delivery of the newborn. The participants in our study were Thai women
who delivered their babies at the mean gestational age of 38 weeks, while in the study by
Estrella et al., they were Filipino women whose babies were delivered at the gestational age of
33 weeks.

The result of this study was similar to the previous study by Espinosa-Kuo [6], which found
that women who took Moringa oleifera capsules had more breast milk per day from postpar‐
tum day 3–10 compared to those who were on placebo. But this was not statistically signifi‐
cant. However, one recent review article mentioned 500 mg/day of Moringa associate with in‐
crease breast milk [15].

The exclusive breastfeeding at 6 months in this study was 52.3% in the Moringa oleifera group.
This exclusive breastfeeding rate met the goals set by the WHO (the rate of exclusive breast‐
feeding for the first 6 months up to at least 50% by the year 2025) [1]. Moringa oleifera may
be used for supporting women who intend to breastfeed exclusively for 6 months.

The strengths of this study were its study design, which was a randomized, double-blind,
placebo-controlled trial conducted to evaluate the efficacy of the Moringa oleifera capsule in
increasing breast milk volume in the early postpartum period. There was no dropout in our
study.

The limitations of this study were the proportion of route of delivery among participants which
was mostly cesarean delivery. This might not represent all postpartum patients. We only
recorded the amount of breast milk on the third day postpartum which might not represent
the whole breast milk production period. Thus, this study does not represent the efficacy of
the Moringa oleifera capsule in increasing the amount of the breast milk during the whole
breastfeeding period; hence further study is necessitated. Further research should be con‐
ducted to include day 3/4/5 of quantification of breast milk amount in comparison to placebo
group and the long-term adverse effects to confirm the clinical benefits of Moringa oleifera in
breastfeeding.

5. Conclusions

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9684698/ 8/10
08/12/23 14.45 The effect of Moringa oleifera capsule in increasing breast milk volume in early postpartum patients: A double-blind, randomize…

Even 900 mg/day of the Moringa oleifera leaf could not significantly increase breast milk vol‐
ume in early postpartum mothers, but the amount of breast milk in the Moringa oleifera group
was 47% more than the one in the control group. The exclusive breastfeeding rate at 6 months
in the Moringa oleifera group achieved the goals set by the WHO. As a result, Moringa oleifera
leaf may be used as a galactagogue herb to increase the volume of breast milk.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal rela‐
tionships that could have appeared to influence the work reported in this paper.

Acknowledgements

The work was funded by a Grant for International Research Integration: Research Pyramid,
Ratchadaphiseksomphot Endowment Fund, Chulalongkorn University and Placental related
diseases Research Unit, Chulalongkorn University, Thailand.

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