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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 period
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.
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.
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