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Introduction:
Domperidone (Motilium™)
is a drug that has, as a side effect, the
increasing of milk production, probably
by increasing prolactin production by the
pituitary gland. Prolactin is the hormone
that stimulates the cells in the mother's
breast to produce milk. Domperidone increases
prolactin secretion indirectly, by interfering
with the action of dopamine, whose action
is to decrease the secretion of prolactin
by the pituitary gland. Domperidone is generally
used for disorders of the gastrointestinal
tract (gut) and has not been released in
Canada for use as a stimulant for milk production.
This does not mean that it cannot be prescribed
for this reason, but rather that the manufacturer
does not back its use for increasing milk
production. However, there are several studies
that show that it works to increase milk
production and that it is safe. It has been
used, for several years, in small infants
who spit up and lose weight, but was replaced
until a few years ago by cisapride (Prepulsid™)
(cisapride has since been taken off the
market because it can cause serious cardiac
problems). Domperidone is not in the same
family of medication as cisapride. Another,
related, but older medication, metoclopramide
(Maxeran™), is also known to increase
milk production, but it has frequent side
effects which have made its use for many
nursing mothers unacceptable (fatigue, irritability,
depression). Domperidone has many fewer
side effects because it does not enter the
brain tissue in significant amounts (does
not pass the blood-brain barrier).
In June of 2004, the Federal
Drug Administration (FDA) in the US put
out a warning against using domperidone
because of possible cardiac side effects.
This unfortunate step was taken without
considering the fact that the cardiac side
effects occurred only when the drug was
taken intravenously by otherwise very sick
patients. In all the years I have used domperidone
in so many mothers, I have not yet heard
of any significant cardiac side effects
that could be attributed to domperidone.
Incidentally, the Federal Drug Administration
has no authority outside the US, and even
in the US, compounding pharmacies, who are
not regulated by the FDA, are continuing
to provide patients with domperidone.
When is it appropriate
to use domperidone?
Domperidone must never
be used as the first approach to correcting
breastfeeding difficulties. Domperidone
is not a cure for all things. It must not
be used unless all other factors that may
result in insufficient milk supply have
been dealt with first. (See handout: Protocol
to increase breastmilk intake by the baby).
What can be done?
1. Correct the baby's latch
so that the baby can obtain as efficiently
as possible the milk which the mother has
available. Correcting the latch may be all
that is necessary to change a situation
of "not enough milk" to one of
"plenty of milk".
2. Use breast compression
to increase the intake of milk (handout
#15, Breast
Compression).
3. Use milk expression
after feedings to increase the supply.
4.
Correct sucking problems, stopping the use
of artificial nipples (handout #5, Using
a Lactation Aid, and #8, Finger
Feeding) and other stratagems.
Using domperidone for
increasing milk production:
Domperidone works particularly
well to increase milk production under the
following circumstances:
- It has frequently been
noted that a mother who is pumping milk
for a sick or premature baby in hospital
has a decrease in the amount she pumps
around four or five weeks after the baby
is born. The reasons for this decrease
are likely many, but domperidone generally
brings the amount of milk pumped back
to where it was or even to higher levels.
- When a mother has a
decrease in milk supply, often associated
with the use of birth control pills (avoid
œstrogen containing birth control
pills while breastfeeding), or on occasion,
for no obvious reason when the baby is
three or four months old, domperidone
will often bring the supply back to normal.
See the handout #25, Slow
Weight Gain After the First Few Months
for reasons milk supply might decrease
and fix what can be fixed.
- Domperidone still works,
but often less dramatically when:
- The mother is pumping
for a sick or premature baby but has not
managed to develop a full milk supply.
- The mother is trying
to develop a full milk supply while nursing
an adopted baby.
- The mother is trying
to wean the baby from supplements.
Side effects of domperidone:
As with all medications,
side effects are possible, and many have
been reported with domperidone (textbooks
often list any side effect ever reported,
but symptoms reported are not necessarily
due to the drug a person is taking). There
is no such thing as a 100% safe drug. However,
our clinical experience has been that side
effects in the mother are extremely uncommon,
except for increasing milk supply. Some
side effects which mothers we have treated
have reported (very uncommonly, incidentally):
- headache which disappeared
when the dose was reduced (probably the
most common side effect)
- abdominal cramps
- dry mouth
- alteration of menstrual
periods
The amount that gets into
the milk is so tiny that side effects in
the baby should not be expected. Mothers
have not reported any to us, in many years
of use. Certainly the amount the baby gets
through the milk is a tiny percentage of
what babies would get if being treated for
spitting up.
Are there long term
concerns about the use of domperidone?
The manufacturer states
in its literature that chronic treatment
with domperidone in rodents has resulted
in increased numbers of breast tumours in
the rodents. The literature goes on to state
that this has never been documented in humans.
Note that toxicity studies of medication
usually require treatment with huge doses
over periods of time involving most or all
of the animal's lifetime. Note also that
not breastfeeding increases the risk of
breast cancer, and breast cancer risk decreases
the longer you breastfeed.
Using domperidone:
Generally, we now start
domperidone at 30 mg (three 10 mg tablets)
3 times a day. In some situations we go
as high as 40 mg 4 times a day. Printouts
from the pharmacy often suggest taking domperidone
30 minutes before eating, but that is because
of its use for digestive intolerance. You
can take the domperidone about every 8 hours,
when it is convenient (there is no need
to wake up to keep to an 8 hour schedule—it
does not make any difference). Most mothers
take the domperidone for 3 to 8 weeks, but
sometimes it is needed longer than that,
and sometimes it is impossible for mothers
to maintain their milk supply without staying
on domperidone. Mothers who are nursing
adopted babies may have to take the drug
much longer. People taking domperidone for
stomach disorders are often taking it for
many years.
After starting domperidone,
it may take three or four days before you
notice any effect, though sometimes mothers
notice an effect within 24 hours. It appears
to take two to three weeks to get a maximum
effect, but some mothers have noted effects
only after 4 or more weeks. It is reasonable
to give domperidone a trial of at least
four, and better, six weeks before saying
it doesn’t work.
For more information
on how to wean off the domperidone see the
handout: Domperidone
2.
See
also the videos
on how to latch a baby on, how to know the
baby is getting milk, how to use compression,
how to use a lactation aid, as well as other
information sheets
on breastfeeding.
Questions? (416) 813-5757
(option 3) or drjacknewman@sympatico.ca
or my book Dr. Jack Newman’s Guide
to Breastfeeding (called The Ultimate Breastfeeding
Book of Answers in the USA)
Handout #19a. Domperidone.
January 2005
Written by Jack Newman, MD, FRCPC. ©
2005
This handout may be copied
and distributed without further permission,
on the condition that it is not used in
any context in which the WHO code on the
marketing of breastmilk substitutes is violated
1. Breastfeeding:
Starting out right
a) The
importance of Skin-to-Skin contact
2. Colic in the Breastfed Baby
3. a) Sore Nipples
b) Treatments
for Sore Nipple and Sore Breasts
4. Is my baby getting enough?
5. Using a Lactation Aid
6. Using Gentian Violet
7. Breastfeeding and Jaundice
8. Finger Feeding
9. a) You should continue breastfeeding
(Medications and breastfeeding)
b) You
should continue breastfeeding (Illness in the mother or baby)
10. Breastfeeding and other foods
11. Some breastfeeding myths
12. More breastfeeding myths
13. Still more breastfeeding
myths
14. More and more breastfeeding
myths
15. Breast compression
16. Starting solid foods
17. What to feed the baby when
the mother is working outside the home
18. How to know a health professional
is not supportive of breastfeeding
19. a) Domperidone 1
b) Domperidone
2
20. Fluconazole
21. Breastfeed a toddler –
Why on earth?
22. Blocked ducts and
mastitis
23. Breastfeeding your adopted baby
24. Miscellaneous treatments for problems
25. Slow weight gain after
the first few months
26. When the Baby refuses to
latch on
27. Expressing Milk
28. Toxins and Infant Feeding
How breastmilk protects Newborns
Risks of formula feeding
Breastfeeding and guilt
Candida protocol
Protocol to increase the intake
of Breastmilk by the Baby ("Not enough milk")
When latching
Protocols for Induced Lactation
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