A critical review of Mohammadpour A, Valiani M, Sadeghnia A, Talakoub S. Investigating the effect of reflexology on the breast milk volume of preterm infants’ mothers. Iranian J Nursing Midwifery Res 2018;23:371-5.
Mohammadpour et al (2018) conducted a clinical trial on the effects of reflexology on the breast milk volume of mothers of preterm infants. The clinical trial aimed to provide new evidence for the effectiveness of reflexology on breast milk volume and further explore the relationship between lactation and reflexology. The trial indicates that reflexology is effective in increasing breast milk volume on mothers of preterm infants. However there are several factors that need to be considered when interpreting the results.
There is no mention in the selection criteria of the mothers of the frequency of breastmilk removal (1) and the effect of preterm delivery on mammogenesis (2) as these are known factors for affecting breast milk volume. As the article itself states, “…the mechanism of milk production is complex, detailed research is required on the relationship between lactation and reflexology”.
The study shows that statistically, reflexology treatment increased breast milk volume for the first four days of the intervention. It is a low cost intervention with no specialist equipment required but does require a commitment of time from both the mother and the person giving the treatment and training of personnel to administer it.
The trial contributes to a small but significant group of research on the effects of reflexology on labour, delivery and lactation (11) (12) (5). It adds to the body of knowledge in this emerging field of reflexology research and shows us how much more there is to discover when there is enough data to generate systematic reviews and meta-analysis. Only then can conclusive arguments be made.
The points stimulated during the treatment given were those generally accepted to affect the areas of the breasts (between the metacarpals of the toes) and the pituitary gland reflex (on the pad of the big toe). The pituitary reflex point is included as the point at which the oxytocin hormone originates (9), Oxytocin causes the ‘let down’ reflex of the milk, pushing milk out of the breast when the breast is stimulated by suckling from a baby or the suction of a breast pump.
All the mothers who participated in the trial had delivered their baby via Caesarian section, which is known to delay the onset of lactogenesis II (10). This puts all the mothers on a level playing field, as mixed delivery methods can not be compared. It is unfortunate that the trial couldn’t have been completed exclusively on mothers who had delivered vaginally, as this is the norm. As the article states “…the impossibility of selecting participants who had had a natural delivery was another limitation of this study”.
I question the ethics of separating the mothers into just the two groups of intervention and control. Would the psychological effects of participating in a study but not knowingly getting the intervention (ie foot massage) have an effect on lactation? Could it be the time taken to receive the intervention, allowing the mothers to sit and relax at an undoubtedly stressful period of their lives have more of an effect than the reflexology itself? We already know that reflexology has been shown to reduce levels of anxiety (3)(4) by reducing stress hormone (adrenaline and noradrenaline) levels and increasing endorphins and oxytocin (5), which has a direct effect on lactation (6). Might it have been a better methodology to separate them into a reflexology group, a general foot massage group and a control group? This may then definitively prove that it is the specific reflex points that are responsible for the increase in breast milk volume. It is unclear what the researchers are trying to prove with their methodology.
The frequency of milk removal from the breast is one of the greatest contributing factors to output volume (7), and timing of early breast milk expression too (8). These factors were not apparent in the selection of the mothers for the trial and their non-compliance in the researcher’s request to not use other interventions to increase milk supply can not be ruled out. Prolactin, the hormone responsible for breast milk production, increases throughout pregnancy, and premature deliveries between 22 to 34 weeks gestation may cause mammogenesis to be incomplete for full lactation (2). Again, this has not been taken into account in this study and will have an impact on the milk volume output, and as the mothers selected are between 29 – 36 weeks gestation, conclusions are hard to draw.
It is a very small scale study and although the statistics drawn from it clearly show there is an increase in breast milk volume in the reflexology intervention group, there are too few participants to say with complete confidence that reflexology has an effect. Further trials must be undertaken, with more precise selection criteria and larger samples to improve our understanding of the reflex points and their effect on breast milk volume. This is an emerging field and this trial shows how much more we have to learn about reflexology and it’s potential benefits. It has shown some interesting and exciting insights into the relationship between reflexology and breast milk volume and I look forward to more research being carried out and published. The stronger the evidence base, the stronger the arguments will be to include reflexology treatment in the care of mothers and their infants during pregnancy, child birth, breastfeeding and beyond.
(1) Infant demand and milk supply. Part 1: Infant demand and milk production in lactating women.
Daly SE, Hartmann PE. 1995.
(2) Complicating influences upon the initiation of lactation following premature birth Cregan, M. D. et al (2007).
(3)Effect of foot reflexology on anxiety of patients undergoing coronary angiography Mahmoudirad et al 2013
(4)The Effect of Foot Reflexology on Anxiety, Pain, and Outcomes
of the Labor in Primigravida Women. Hanjani et al 2013
(5) A concept analysis: the effect of reflexology on homeostasis to establish and maintain lactation. Tipping et al 2000
(6) The Womanly Art of Breastfeeding, La Leche League International, 8th edition, Pinter & Martin.
(7) Breastfeeding and Human Lactation, Riordan & Wambach, 4th edition, Jones & Bartlett
(8) Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: a pilot study.
Parker LA1, Sullivan S, Krueger C, Kelechi T, Mueller M.
(9) Reflexology in Pregnancy and Childbirth, Tiran, 1st edition, Churchill Livingston.
(10) Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Dewey KG1, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. 2003.
(11) The Effect of Reflexology on Pain Intensity and Duration of Labor on Primiparas. Dolatian et 2011
(12) Reviewing the effect of reflexology on the pain and certain features and outcomes of the labor on the primiparous women Mahboubeh et al, 2010