Drug therapy for postpartum lactation promotion
Drug therapy for postpartum lactation promotion should be reserved for individuals who have low supply of breast milk despite nondrug measures. Drug therapy has only a modest effect and evidence for specific drug regimens in lactation promotion is limited. Options for drug therapy are domperidone and metoclopramide. Domperidone is preferred because it has fewer adverse effects on the breastfeeding parent. Neither drug has been reported to have adverse effects on infants; domperidone is transferred in much smaller amounts to the infant, but it is not known whether this has clinical significance.
Domperidone can increase the QTc interval, but there is no evidence to support routine electrocardiograph monitoring before use. The absolute risk of ventricular arrhythmia in young healthy individuals without risk factors is likely to be very low. Use with caution or seek advice if the patient has a personal or family history of a cardiac condition, is taking a drug that prolongs the QTc interval or a cytochrome P450 3A4 (CYP3A4) inhibitor. Potential withdrawal effects (eg agitation, insomnia) in the breastfeeding parent associated with stopping domperidone are anecdotal and a causal relationship is not certain.
Metoclopramide crosses the blood-brain barrier. It should only be used as a single course of 5 days because risks of serious adverse effects increase with duration of use (eg palpitations, depression, dizziness, headache, involuntary grimacing and tremors).
A suitable regimen is:
1 domperidone 10 mg orally, three times daily. If response is not sufficient at 1 week, consider increasing the dose to 20 mg three times daily. Once effective milk supply is achieved, trial a reduction to twice daily dosing. Continue for a maximum total of 4 weeks, then stop therapy, or reduce dose gradually and then stop lactation promotion domperidone
OR
2 metoclopramide 10 mg orally, three times daily for up to 5 days. lactation promotion metoclopramide
If response to the initial dose of domperidone is insufficient after 1 week; a trial of a higher dose may be beneficial. Evidence for benefit of a higher dose is limited; small studies show nonsignificant increases in milk supply. Domperidone may take 2 to 4 weeks to achieve maximum benefit. Use beyond 4 weeks is not generally advised for a single course; however, tapering the dose slowly from 4 weeks can be considered if the breastfeeding parent is concerned about a potential fall in milk supply. Individual assessment is required. Evidence of a protective effect on supply or an optimal regimen for tapering is lacking. If supply falls after stopping, further courses of domperidone can be considered with individual assessment.
Data is limited on the safety and efficacy of other lactation-promoting drugs such as oxytocin, prolactin, metformin and herbal medicines (eg fenugreek, milk thistle).