TEMA 8. HIERBAS MEDICINALES

8.1 FUNDAMENTOS GENERALES

Está demasiado extendido erróneamente que lo natural es seguro, pero no siempre es así. Es importante dejar claro que, lo “natural” no es sinónimo de “seguro o inocuo” y, de hecho, hay plantas provistas de alto grado de toxicidad. No en vano las plantas o hierbas medicinales han sido un modelo para la síntesis de diversas estructuras químicas con farma que conforman nuestra Farmacopea.

Las plantas medicinales, al considerarse suplementos dietéticos, no requieren aprobación previa de la FDA en seguridad y eficacia antes de comercializarse, aunque sí existen requisitos de fabricación, etiquetado y control postcomercialización. La mayor preocupación reside en la ausencia de controles de eficacia y toxicidad (Lawrence 2010). De hecho, en el etiquetado de este tipo de productos en EE. UU. puede leerse “este producto no pretende diagnosticar, tratar, curar o prevenir ninguna enfermedad”.

Si bien es cierto que muchas hierbas pueden ser aceptables en cantidades alimentarias, el riesgo cambia coninfusiones concentradas, extractos, tinturas y sobre todo aceites esenciales, que no deben tratarse como equivalentes a una especia de cocina. En anís e hinojo, LactMed sigue recogiendo casos de toxicidad neonatal tras un consumo materno excesivo de mezclas herbales con estos ingredientes.

El consumo de fitoterapia ha ido en aumento en paralelo al interés que suscita una alimentación saludable (Siegel 1976).

Precauciones al tomar preparados de plantas (Anderson 2017, Powers 2015, Posadzki 2013, Efferth 2011): 

Asegurarse que son de fuente fiable: Han ocurrido intoxicaciones por confusión de una planta con otra con propiedades tóxicas, envenenamientos por contener metales pesados que extraen del suelo y toxiinfecciones alimentarias por contaminación con bacterias u hongos.
No tomar en exceso; seguir recomendaciones de profesionales expertos en fitoterapia. Los productos “naturales” no son buenos en cualquier cantidad: las plantas contienen sustancias activas de las que se ha obtenido gran parte de nuestra farmacopea tradicional y pueden provocar intoxicaciones o actuar como disruptores endocrinos (contienen fitoestrógenos) si se consumen en cantidad o tiempo exagerados. No obstante, muchas mujeres se sienten seguras y reconfortadas tomando alguna infusión y las prefieren a medicamentos y sobre todo a malos consejos y malas prácticas de apoyo a la lactancia.

8.1.1 Efectos indeseables de las plantas

Componentes tóxicos presentes en dichas plantas y que se excretan a la leche materna y pueden causar efectos indeseables en el bebé.
Tienen un efecto indeseable en los niveles de prolactina y, por tanto, pueden disminuir la producción de leche.
Pueden conferir un sabor indeseable a la leche y el bebé la rechaza (diente de león, cúrcuma…etc.)

8.2 PLANTAS MEDICINALES CONTRAINDICADAS DURANTE LA LACTANCIA

Plantas con tuyona: están totalmente contraindicadas, debido a que este componente se excreta a la leche materna. Algunas se usan como aromáticas, en cuyo caso, si se toman de forma esporádica y en bajas concentraciones, probablemente el riesgo sería bajo, aunque por prudencia, no se recomienda. Se desaconseja el uso de estas plantas en infusión, tinturas o como aceites esenciales.

La tuyona es un compuesto que se encuentra en el aceite esencial de muchas plantas y se relaciona con el alcanfor. Es tóxica para el hígado y el sistema nervioso además la tuyona confiere un sabor y olor característico a la planta (ej. Ajenjo).

Plantas purgantes: también se debe evitar infusiones laxantes con plantas purgantes, pueden excretarse a la leche materna y estimular fuertemente el intestino del bebé y provocando fuertes dolores de vientre. Las principales plantas purgantes son las siguientes: cáscara sagrada, hojas de sen, frángula, ruibarbo.

Con respecto a las hojas de sen, las últimas publicaciones (Budzynska 2012) confirman su prácticamente nulo paso a leche lo que le hacen compatible con la lactancia, siempre que no se abuse de ella ni se tome de forma prolongada.

Plantas ricas en salicilatos: por precaución no se recomienda su uso. Los salicilatos en la leche materna pueden producir exantema en el bebé. Plantas con salicilatos: Reina de los prados, sauce, abedul y ulmaria. Se ha descrito hemorragia gastrointestinal en un niño de 4 años que tomó un jarabe que contenía Ulmaria y Sauce, ambas plantas ricas en salicilatos (Moro 2011). Asimismo, debido al elevado contenido de ácido salicílico que se excreta en leche materna (no es el caso de la Ulmaria), existe el riesgo teórico (no publicado) de aprovocar un síndrome de Reye en el lactante.
Agracejo (Berberis vulgaris): se utiliza la raíz, la corteza y los frutos de la planta.
La raíz y la corteza contienen alcaloides isoquinolínicos como berberina, berbamina, oxiacantina y palmatina (Skidmore 2010 p 43, WHO 2009 p 30).
Uso en medicina tradicional sin eficacia claramente demostrada en afecciones urinarias y gastrointestinales, como antiinflamatorio y, en forma tópica, para inflamaciones cutáneas y oculares. La berberina puede provocar gastritis, nefritis, fototoxicidad e ictericia grave por desplazamiento de la bilirrubina ligada a la albumina: riesgo de kernicterus en recién nacidos, mayor en caso de déficit de Glucosa-6PD (Rad 2017, Chan 1993).
Planta no aprobada por la Comisión E del ministerio de salud alemán para uso terapéutico (Blumenthal 1998 p 309). Dadas las escasas referencias bibliográficas de esta planta, su falta de indicaciones comprobadas y su posible toxicidad, su consumo habitual es prescindible y más durante la lactancia (Skidmore 2010 p 47, WHO 2009 p 30). El uso tópico sería compatible con la lactancia a condición de no aplicarlo sobre el pecho para evitar que el lactante lo ingiera; caso necesario, aplicar tras una toma y limpiar bien con agua antes de la siguiente. El uso de los frutos como alimento también es compatible con la lactancia por no contener ningún alcaloide.
Anís estrellado (Illicium verum): se usan los frutos del árbol. Contiene aceite esencial (rico en trans-anetol, -85%-, anisatina y estragol), flavonoides y taninos (De Groot 2016, Mathon 2013). Propiedades atribuidas: antiespasmódica, carminativa, expectorante, agonista estrogénico. Indicaciones Comisión E del Ministerio de Salud alemán: anorexia, tos, bronquitis (Blumenthal 1998 p 215). El anetol es neurotóxico (Mathon 2013, Ize 2004) y se elimina por la leche (Hausner 2008). Dos lactantes menores de un mes se intoxicaron gravemente (letargia) tras beber sus madres una media de dos litros diarios de una infusión mezcla de regaliz, hinojo, anís y galega. Se atribuyó el efecto al anetol del anís y el hinojo (Rosti 1994). Hay mucho riesgo de contaminación accidental con Illicium religiosum (Illicium anisatum, anís estrellado japonés) no comestible, muy tóxico (Techen 2009, Ize 2004, Minodier 2003, Vandenberghe 2003) y retirado del mercado en España (MSC 2004) y con advertencias en otros países (FDA 2003, n.a.l. 2003). Numerosos lactantes han tenido intoxicaciones graves con episodios convulsivos tras la administración directa (no a través de la leche materna) de infusiones de anís estrellado, contaminado o no con anís estrellado japonés (Casanova 2019, Obando 2016, Madden 2013, Perret 2011, Ize 2004, Minodier 2003, Johanns 2002, Gil 2002), motivo por lo que en España fue retirada temporalmente la comercialización de anís estrellado en 2001 (Europa Press 2001, Gil 2002). Un consumo ocasional o moderado de anís estrellado por parte de la madre podría ser compatible durante la lactancia, pero no administrado directamente al lactante, es decir, no es una infusión “de rutina” aconsejable.
Artemisa (Artemisia vulgaris): planta tradicionalmente empleada para tratar enfermedades o afecciones de la mujer (de Boer 2014, Kim 2013), sin que se haya podido probar su eficacia (Blumenthal 1998). Existe muy poca bibliografía sobre sus propiedades. Se le suponen propiedades uteroestimulantes. Se utilizan las sumidades floridas y la raíz de la planta. No se recomienda su consumo por su alta concentración en productos potencialmente tóxicos como alcanfor, eucalipto, tuyona y lactonas sesquiterpénicas. A fecha de última actualización no encontramos datos publicados sobre su excreción en leche materna. Dada la falta de pruebas de su eficacia y su potencial efecto tóxico, se desaconseja su uso en general y más en niños y madres embarazadas o lactantes (Skidmore-Roth 2011, Blumenthal 1998).

Regaliz (Glyxyrrhiza glabra): se usa la raíz de esta hierba leguminosa. Contiene aceite esencial, cumarinas, flavonoides, terpenoides (glicirrizina) y fitoestrógenos. Las propiedades que se atribuyen son como antiulceroso y expectorante y las indicaciones de la Comisión E Ministerio de Salud alemán son como tratamiento para la gastritis, ulcera, tos y bronquitis. El abuso o uso prolongado de regaliz puede causar graves problemas de salud por sus efectos mineralcorticodeos: pseudoaldosteronismo, parálisis hipokaliémica, hipernatremia, edema, arritmias cardíacas e hipertensión arterial (Robles 2013, Panduranga 2013, Penninkilampi 2017, Deutsh 2019). Especial precaución durante el embarazo dado que puede provocar aborto y parto prematuro. Tiene efectos estrogénicos y antiprolactina, por lo que podría disminuir la producción de leche durante las primeras semanas del puerperio (Zava 1998). Se ha publicado un caso de hiperprolactinemia (Werner 1978). No hay ningún dato comprobado de su efecto como galactogogo y, de hecho, sí se ha constatado que reduce la prolactina sérica (Le Moli 1999). La glicirricina, responsable de muchos de los efectos del regaliz, se excreta en pequeña cantidad en leche materna (Lacmed).
Cimifuga (Cimicifuga racemosa): contiene saponósidos, fitoestrógenos, etc. Se le atribuyen efectos estrogénicos y se emplea para la menopausia, síndrome premenstrual y la dismenorrea (Leach 2012). Los fitoestrógenos pueden disminuir la producción y alterar la composición de la leche.
Poleo menta o poleo (Mentha pulegium L.): por su contenido en pulegona, está totalmente contraindicado la infusión de poleo menta durante el embarazo y lactancia. La pulegona es abortiva durante el embarazo y resulta tóxica a nivel hepático, renal y neuronal (Zhou 2004; Bunchorntavakul 2013). Se encuentra sobre todo en el aceite esencial de la planta y en menor dosis en las infusiones, pero se han detectado casos de intoxicación graves en lactantes que tomaron pequeñas cantidades de infusión poleo menta (Bakerink 1996).
Aceite de ricino (Ricinus communis): tradicionalmente se ha utilizado como galactogogo, aunque también para justo lo contrario, disminuir la producción de leche (Hardy 2000, Eglash 2014). El aceite de ricino se utiliza por vía oral como laxante. El ácido ricinoléico irrita la mucosa intestinal y se absorbe, pudiendo llegar a la leche. Es prudente utilizar laxantes alternativos más seguros durante la lactancia. Asimismo, se emplea tópicamente como antiinflamatorio de la piel. Al contener las semillas ciertas cantidades de ricina, principio activo muy tóxico, se desaconseja totalmente el consumo de éstas. Su uso tópico sí sería compatible con la lactancia.

8.2.1 Especial precaución con las infusiones de anís e hinojo

El anís (Pimpinella anisum L.) y el hinojo (Foeniculum vulgare) son las infusiones más utilizadas durante el embarazo y lactancia (Sibeko 2021, Kaygusuz 2021, Badgujar 2014).

Se usan los frutos de la planta. Contiene aceite esencial (anetol 60-80%, estragol 5-10% y fenchona 7-15%), cumarinas y flavonoides (Fitoterapia.net, Dosoky 2021, Badgujar 2014, WHO 2010 p 127-140). Tienen propiedades carminativas y antiespasmódicas y se recomiendan en los cólicos del lactante (Harb 2018, Gordon 2018).

Los componentes del aceite esencial (trans-anetol, estragol y fenchona) se excretan en leche materna en pequeña cantidad (Denzer 2015, Hausner 2008).
La administración a madres lactantes de una infusión comercial que contenía anís, cilantro, fenogreco e hinojo no produjo efectos adversos en sus hijos lactantes (Wagner 2019).
El exceso de consumo materno (2 litros/día) de una infusión mezcla de anís, galega, hinojo y regaliz causó letargia, vómitos e hipotonía en dos lactantes y en sus madres (Rosti 1994).

El anetol, a dosis elevadas, es neurotóxico y convulsionante (Bahr 2019, Skalli 2011, Burkhard 1999) y tiene débil actividad mutagénica. El hinojo tiene actividad estrogénica (Dosoky 2021, Amir 2011, Türkyilmaz 2008) y ha provocado telarquia prematura en niñas pequeñas que lo tomaban para tratamiento de cólicos abdominales (Türkyilmaz 2008).
El estragol tiene efecto carcinogénico en animales. En humanos, a dosis recomendadas, no se ha encontrado este efecto. No se ha podido demostrar mayor capacidad antioxidante en la leche de mujeres que bebieron infusiones mezcla de esta y otras plantas (Kavurt 2013). Aceites esenciales ricos en anetol no deben consumirse durante la lactancia, el embarazo y si se padece un cáncer estrógeno-dependiente (Dosoky 2021).

No hay pruebas fidedignas de que aumente la producción de leche (Sibeko 2021, Foong 2020, ABM 2018 y 2011). La administración a las madres lactantes de infusiones de hinojo o de una mezcla de hierbas que contenía hinojo no produjo aumento de prolactina, ni mayor aumento de peso de los lactantes, aunque se apreció mayor producción de leche que en los grupos control (Özalkaya 2018).

El consumo moderado en cantidad y duración de infusiones de hinojo sería compatible con la lactancia.

8.3 ACEITES ESENCIALES

Los aceites esenciales contienen los principios activos a altas concentraciones que se extraen de determinadas partes de ciertas plantas (Vigan 2010) y presentan actividad biológica muy diversa. Las indicaciones terapéuticas de los aceites esenciales son innumerables e incluso se están utilizando en aromaterapia para paliar los efectos secundarios de ciertos tratamientos oncológicos en determinados tipos de cáncer (Bakkali 2008, Reis 2017).

Los aceites esenciales pueden resultar tóxicos a dosis moderadas y a dosis altas pueden desencadenar reacciones muy graves (Farrar 2020). Hay que tener en cuenta que son necesarios kilos y kilos de plantas para obtener unos pocos mililitros de aceite esencial. Asimismo, su alta liposolubilidad los hace muy proclives a excretarse y concentrarse en la leche materna por lo que conviene evitaros durante la lactancia. Asimismo, conviene tener precaución con su aplicación tópica alrededor del pecho. Un ejemplo sería el aceite esencial de lavanda con actividad estrogénica y se aconseja evitar la aplicación tópica alrededor de la mama.

Hay que tener en cuenta que su calidad y composición varía mucho entre diferentes marcas comerciales.

Su etiquetado suele ser confuso y pueden contener perfumes o ciertos ingredientes no aptos (incluso tóxicos) para consumo vía oral.

Son extremadamente concentrados y tienen que usarse bajo consejo profesional, para consumo oral normalmente deben diluirse primero.

Su ingesta no se recomienda durante la lactancia y por vía tópica habría que valorarlo y siempre diluido (evitar la zona del pecho).

Con respecto a su uso por inhalación, los aceites esenciales en aromaterapia se están utilizando en niños pequeños (incluso en bebés prematuros) con buenos resultados y sin efectos indeseables (Usta 2021).

8.3.1. Precaución con los aceites esenciales

Un uso inadecuado de aceites esenciales, por ejemplo, aplicarlos sin diluir, en exceso, sobre mucosas, puede dar reacciones adversas. Igualmente está contraindicado su ingesta oral sin diluir.
Se desconoce toxicidad de la mayoría de los aceites esenciales.
No hay datos publicados de si se excretan a la leche materna pero su alta liposolubilidad lo hace altamente probable.
Sensibilidad individual a los componentes del aceite esencial.

Especial precaución con aquellos aceites esenciales que contienen:

Tuyona
Anetol (trans-anetol)
Estragol
Pulegona
Ascridol
Safrol

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