Introduction

Breast milk have numerous health benefits. Breast milk is rich in nutrients that babies’ needs for their healthy growth and development, including the proper amounts of proteins, carbohydrates, fats, minerals, lymphocytes, antibodies, immunoglobulin IgA, digestive enzymes and water. WHO recommends exclusively breastfeed during first six months after baby birth.  Ayurvedic literature also provides a nice explanation of the value of breast milk and the advantages of breastfeeding. But, due to changing lifestyles and poor eating habits, it has become clear that most mothers have insufficient breast milk secretion. In Ayurveda, this condition has been described as stanyakshaya. The secretion of 300 mL (10 ounces) every day by day five and 480 mL (16 ounces) by day ten is considered to be adequate lactation. Also, if the baby is satisfied and sleeps for2–3 hours after breastfeeding, passing urine 6–8 times in 24 hours with sufficient weight gain, this considered mother is having sufficient milk secretion (1). In lactational deficiency, there is an insufficient milk secretion, infant will not receive enough nutrition which results in insufficient weight gain of baby and leads to many diseases condition. Globally, the prevalence of lactational insufficiency ranges from 23% to 63%, but it may be as high as 30–40% in Asian and tropical nations like India (2). Stanya is a upadhatu of Rasa Dhatu formed from the sweet essence part of Rasa after proper digestion of food. (3)  A lactating mother's qualities, the qualities of sthanya, the advantages of breastfeeding for both mother and baby, are all thoroughly explained in Ayurveda. Many Acharyas, including Charaka, Sushrutha, Vaghbata, Bhavaprakasha and Kashyapa, described the causes of Sthanyakshaya. Mainly the mother's psycho-somatic issues and her diet are what lead to Sthanyakshaya. Lactation failure is a serious problem that needs to be treated as early as possible. In Ayurveda many medication, diets, and behavioral regimens are mention as Sthanyajanana and helps in the treatment of SthanyaKshaya.

AIM: To do a conceptual study on stanyakshaya and to find out updates on milk insufficiency/lactation insufficiency and its Ayurvedic management.

OBJECTIVE: To study the incidence, pathophysiology, causes, clinical features of milk insufficiency or lactation insufficiency as per modern view as well as Ayurvedic view.

MATERIAL AND METHOD: Data Source: literary review on the issue was performed by searching publications from the Medline database and from national and international organizations. reference books and classical Ayuredic Samhitas. Some key articles cited in other sources such as PubMed and other Web sites were selected which include literature on stanyakshaya comes from both Ayurvedic and modern sources.

Review of Stanyakshaya-

As Compared to previous years, the prevalence rate of lifestyle diseases and infectious disease is much higher in the present time. Breast milk plays an important role in overall health and immunity. The insufficient supply of breast milk negatively affects the growth and development of baby. Nowadays, due to various reasons, stanyakshaya is very common in our society. This topic and its effective Ayurvedic management strategies need to be explored. Ayurvedic knowledge about breast milk is unique. Physiology of stanya, its quality, purity examinations, dushti, and stanyakshya is seen in classic Samhita of Ayurveda. Dugdha, Kshira, Payas, Stanya, and Balajivana are synonyms of Stanya (4).

Stana Parikshana: Darshana, sparshana, and prashna are the three methods of Ayurveda. Darshana can be used to determine the shape of the breast. The breast develops completely during puberty. In garbhavasta stana, twacha is peeta (yellow), but after labor, peetata is reduced and twacha returns to its normal color. Neelavarniya siras are more visible when there is excessive stanya. In normal stanya ashaya, the stanapurnatva can feel the stana. In stanyakshay, the breasts seem to be loose and lax (Stana mlanta). Little bit information regarding milk production and breast related issue can be collected by asking questions to mother (5).

Properties of breast milk: According to Acharya Kashyapa, breast milk provides strength, longevity, and helps in sufficient growth and development of the baby. Furthermore, it also ensures the development of a disease-free state and provide comfort of a child and its mother (6). As per pramanasharira in Ayurveda, the quantity of stanya is two anjali. The normal colour is pandura or shakhavabhasa. Stanya has madhura rasa and kashaya anurasa, smell like madhu (madhugndhi), laghu in nature easy for digestion, sheta veerya, madhura Vipaka (7).  In Ayurveda, a plain water test is used to test the breast milk's quality. The milk is said to be pure, when a drop of milk is put in plain water, it forms a homogenous mixture (8).

Physiology of stanya formation:According to Acharya Sushruta lactation is begin three days following parturition. The rasa is formed as a result of food digestion. The sweet essence, a component of this rasa, reaches the breasts via the action of vyana vata and is called as stanya. Rasa and stanya are both derived from the essence of rasa dhatu. Acharya Bhava Misra and Yogratnakara have the same view. Acharya Charaka, Sushruta Acharya and Acharya Bhela explained the concept of garbhaposhana by stating that the aahara consumed by garbini has three purposes: Matrupushti, Garbhaposhana, and Stanapushti. According to Charaka, Stanya is nourished by rasadhatu. Sarangadhara considered stanya as a updhatu of rasa dhatu, with the latter passing through kshiravahisira and mixed with pitta before reaching Jathara.Agni digests it there, transports it to the breast's siras, and then it is expelled. Milk is the secretion that is associated with agni and soma. The blood, due to the action of pitta, gets suppurated and becomes white.  While describing garbhaposhana in Astangasangraha, it is explained that stanya is formed from the ahara rasa itself. Both Raja and Stanya derive from the essence of rasa, with Stanya being the upadhatu of rasadhatu. As a result, the preceding description mentions the formation of stanya from ahara- rasa and rasa-dhatu.  While describing the raktagulma, Maharshi Kashyapa states that some of the mother's blood nourishes the fetus's body parts, some are used to produce breast milk, and the remain is used to nourish the mother's body. So, he explains the formation of stanya from rakta. Furthermore, he explains that raja (blood) forms breast milk immediately after the birth of the fetus. So, he explains stanya is formed from raja. In Astanga Sangraha, Acharya Vagbhata describes that the channels of menstrual blood get blocked by the fetus. Hence, no menstrual blood will flow. Thus blocked, it goes down the downward path that leads to the formation of the apara; some say it forms the jarayu. The blood that remains after the formation of the jarayu moves and is associated with kapha, which aids in the production of breastmilk. So, he describes Stanya evolved from Raja. Bhela has included stanya among the ten pranayatanas. Finally, according to different Acharyas, stanya is derived from Ahararasa Rasa, Rakata, and Raja.

Mechanism of Milk ejection: After delivery on the 3rd or 4th day, the dhamanis or siras situated in the Hridaya region get dilated and start milk ejection (the ejection reflex). According to Harita, the delivering woman's bearing- down efforts cause her srotases to clear, resulting in unexpected milk ejection. However, because of the kapha dominance, this milk is thick and should be discarded (9). Bhavaprakasha, Madhavanidana, and Susruta all agree on the stanyapravrutti. According to modern physiology, the lactation is primarily determined by two hormones. The anterior pituitary gland secretes prolactin to stimulate milk production, while the posterior pituitary gland secretes oxytocin to stimulate milk ejection. Many psychogenic factors or even generalized sympathetic nervous stimulation throughout the mother's body can inhibit oxytocin secretion which results in decrease milk ejection. Colostrum (stanyapiyusha) is the first breast milk produced after giving birth. It is a viscous, lemon-yellow secretion from the breast that appears between the late third and fourth trimesters and the fourth day after birth. There are ninety known components in the colostrum, including immune factors and growth factors (10).

Stanyakshaya

Nidana: Along with the overall debilitating factors of parturition, such as blood and energy loss, our Acharyas have identified additional risk factors. Excessive consumptionof ruksha (dry edibles and drinks), karshana (emaciation), langhan (fasting), atyapatarpan (excessive fasting), annapana and viharas, which cause vatavridhi, have a negative impact on stanya. The psychological and behavioral elements Krodha (anger), Bhaya (fear)Shoka (grief), Kaama (excessive coitus), and avaatsalya (lack of affection for the infant). Furthermore Punagarbhadhaaran (re-pregnancy) and the practice of excessive shodhana karma (purifying methods used in excess) these are the contributing reasons for stanyakshaya. The next pregnancy will cause hormonal changes resulting in lactation failure. Lack of sufficient stimuli (both psychic and somatic stimulation is required for effective lactation) decreases the production. Some mother will naturally have less milk or no milk, which includes swabhavika stanyakshaya, or stanyanasha

Stanyakshaya Samprapti (pathogenesis)- In sutika, there is dhatukshaya awastha due to pravahanvedana (labor pains and bearing down efforts) and loss of rakta and kleda during prasava. As a result, mother suffers from deficiencies in bala (strength) and agni (digestive power). Apathy sevana (atyaapatarpana, rukshaanna, shoka, bhaya, krodha) further complicates things. As a result, vatapradhana tridosha prakopa occurs, resulting in rasa dhatukshaya which result in to upadhatukshaya (stanyakshaya) (11). Emotionally oriented oxytocin release (the let-down reflex) in association with prolactin contributes to the proper production and sustenance of lactation. These psychophysical phenomena are well plotted in the Samprapti of Stanyakhaya.

Stanyakshayalakshana; Stanamlaanata (breast laxity) as a sign of stanyakshaya in addition to the absence or reduction in stanya(12).

Management of Stanyakshaya- The etiological factors of stanyakshaya lead to rasakshaya hence treatment should be directed toward normalizing rasakshaya. Rasadhatu and Sleshma are related through the Asrayaasrayi relationship. The Bruhana, Snigda, and Madhura treatments should be used. Uses of Sleshmavardhaka dravyas (articles increasing sleshma or kapha), Maansa (meat) Sura (wine), Shaalianna, cow’s milk, Asava, Sharkara (sugar) and Curd. The Practice of Milk production promoting diet, which includes Madhura (sweet), amla (sour), lavana (salt) rasa, ksheerapaana (milk intake), meat soup, ghrita taila, all leafy vegetables except siddharthaka, Naadishaka is cooked with jaggery, jatiphala and hingu. Stimulate Milk production with the help of foods such as narikela (coconut), palandu (onion), Yava (barley), lashuna (garlic), wheat, shaali (rice, Oryza sativa), shashtika (a variety of rice harvested in 60 days), matasya (fish), kanji (fermented sour drink), pinyaka (sesame seed paste), kasherukashringataka and all wines except sidhumadya (13).

Stanyajanana and Stanyavardhaka drugs: The Ayurvedic Samhithas has explained several drugs and formulations that have potential quality to enhance breast milk These include,

 -Making a decoction from the roots of veeran, shaali, shashtika, ikshuvaalika, darbha, kusha, and kasha as well as gundra, itkata, and ktrina (all are different types of grasses). These drugs are together called stanyajananamahakashaya, which is explained in these drugs containing ksheera (apparent latex).

-Milk is medicated with a decoction of Stanya janana.

-Milk infused with pippalimoola, shunthi, maricha (black pepper), pathya (haritaki) and guda. (14)

-Milk treated with vaajikaran medications also promotes lactation (15).

-Milk is treated with a decoction made from the stem barks of latex-producing trees like vata and udumbar, among others. This milk sauwarchala is then mixed with cooked shaali and served with jaggery, salt and ghee. Even in fully dry breasts, lactation is supposed to start with this preparation (16).

-Milk flavored with a mixture of Vidaarikanda, Shringataka, and Vari (Shatavari) juice or powder.

-According to digestive capacity, pippali, pippalimoola, chavya, shweta, shunthi, yawanika, and krishanjirakas are administered, along with haridra, daruharidra, and sauwarchala salts prepared with kaanji. This mixture also has galactogogue activity (17).

-Sheetaveerya    madhuravipaka, ushanveerya-katuvipaka and ushnaveerya- madhuravipaka, are some of the drugs with galactagogue action (18). Most of the drugs are dhatunpushtikara, balya, and deepanapaachana in nature. Because of these properties, it can stop and repairs Rasa dhatukshaya,       Agni            mandhyata(Jatharagni           and Stanavahasrotoavrodha, Rasdhatvagnimandhyata) which are the somatic causes of stanyakshaya(19).

Factors that promote lactation include- By getting into a pleasant mood, one can induce the posterior pituitary through the limbic system to get the maximum letdown reflex (20). Once you live with Saumnasya (joy), which means avoiding exertion and hard work, getting enough sleep, avoiding grief and fear and remaining calm and concerned about the baby, you will have sufficient lactation.

Discussion

Variety of conditions result in inadequate milk production while breastfeeding. Delayed breastfeeding and an extended period between feedings are the foremost causes of insufficient flow. Mothers rely on formula feed rather than breast milk because of their hectic lifestyle. Modern lifestyles and food habits lead to nutritional deficiency for mothers, which also causes breast milk insufficiency. Other contributing factors include lactational mastitis, use of hormonal medications, consuming tobacco, smoking, drinking and using oral contraceptives that include estrogen (21). Stasnyakshaya also have stress or anxiety- induced pathology. Stanya and Artava are upadhatus of Rasa. Upadhatus are, by definition, those that are nourished by the corresponding dhatus. It's important to understand the basics of rasa dhatu, only a properly constructed rasa dhatu can generate stanya that is both qualitatively and quantitatively healthy. According to Kasyapa, stanya is created from rakta; after fertilization, a small amount of blood feeds a pregnant woman's breast milk. Rakthadhatu's ability to produce breast milk may be influenced by hormonal changes that occur during lactogenesis and Mammogenesis. Blood carries the breast milk-producing hormone even though that upadhatu cannot nourish other components of the body, the Raja does nourish Stanya. Raja, following the development of garbha, rises up to Stana, where, due to the activity of Pitta, Raja becomes Stanya after changing from red to a delicate white color. The "Piyusha (colostrum)" actually has this kind of stanya.  As Stanas the mulasthana of Shukra, there must be a pathway for both streeshukra and artava to pass through in females; hence, this obstructing aartav results in Vimargagamana of that which eventually reaches Stana. Hence, the pitta transforms it into Stanya physically. This is related to hormones like estrogen, progesterone, prolactin, oxytocin, contribute to the production of Stanya. The mother's ahara and vihara play a major role in determining the quality and amount of stanya. Hence, stanyakshaya can be manage by the using of aharas and herbal medications, which possess the ability to induce or enhance milk production. The ahara and oushada dravyas, which act on rasadhatu kshaya, Agni mandya, stananyakshaya, sroto avarodha, and Manasikabhava, can effectively correct stananyakshaya.

Conclusion

Breastfeeding has significant and long-term health advantages. Breastfeeding is the ideal feeding source for infants. Stanya Kshaya is most common issue identified in our clinical practice. Stanyakshaya, Agni Mandhyata (Jatharagni and Rasdhatvagnimandhyata), Maansikabhava (shokabhaya - avaatsalya) and Stana vahasrotoavrodha are the four main causes of this condition. Stanyakshaya result in a lack of nourishment and have an impact on the infant's general development. considering the psychic and somatic condition of lactating mothers, Ayurveda can manage this condition effectively and safely. Healthy lactating mothers can use stanyajanan and Stanyavardhaka medicine, especially in sutikaavastha, for enhancement of breast milk production to treat lactational insufficiency.