Domperidone: How far will you go to increase breast milk supply?

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Find out why this galactagogue is illegal to distribute in the United States and if it is indeed worth taking to increase breast milk supply.

Breastfeeding a newborn sometimes is no walk in the park, but breastfeeding mums will tell you that the ups and downs of the journey are absolutely worth it.

There is often pain, coupled with frustration, as the sleep-deprived mum tries to teach her newborn this life skill, which with practice, good technique, and a great support system, soon enough becomes second nature to mother and child.

Though cheaper than formula-feeding, there are still costs involved; and the everyday struggle of fitting it into one’s lifestyle is as real as having circular stains on one’s chest while at the husband’s office party.

Then there is the constant concern of increasing breast milk supply – from regulating one’s supply in the early days of breastfeeding, to keeping up with baby’s ever-increasing demands. This is especially hard for pumping moms who don’t have the communication between baby’s hunger cues and their production going.

The go-to techniques to increase breast milk supply include breast massage and hand-expression, increasing feed frequency, and intake of galactagogues and supplements.

There are moms, however, who have taken to prescription drugs to remedy the situation. It may sound a tad extreme, but it is effective. Now the question that every mom finds herself asking at least once a day, “Is it safe?”

Domperidone: Is it safe?

A popular drug used to boost milk supply is Domperidone (Motilium). Marketed for relief of gastric pains like indigestion, Domperidone is also used for nausea and vomiting.

A side effect of the drug is causing a rise in prolactin levels. Prolactin is the hormone that stimulates milk production, often called the “mothering hormone”.

Although it’s a prescription drug in Singapore, it is actually illegal to distribute in the USA, as it is not approved by the FDA, stating:

“The risks of cardiac arrhythmias, cardiac arrest, and sudden death outweigh any potential benefit of domperidone in healthy lactating women.”

Whoa. How did we go from prolactin increase to cardiac arrest?

A breastfeeding cardiologist explains that Domperidone prolongs the QT interval, altering certain electrical currents in the cardiac muscle cells, making them susceptible to an abnormal heart rhythm called torsades de pointes.

An ECG where the long QT interval is evident

An ECG where the long QT interval is evident Photo from: EKG World Encyclopedia cme.med.mcgill.ca/php/index.php , courtesy of Michael Rosengarten BEng, MD.McGill

She calls QT-prolonging silent killers because the first symptom is ‘dropping dead’ from a malignant arrhythmia.

If the risk is so great, why are breastfeeding experts like Dr. Jack Newman calling it “a relatively safe drug” and using it on so many mothers?

What you need to know about Domperidone:

  1. Its cardiac side effects are contingent on certain factors

Dr. Newman says it’s only dangerous when given intravenously to already sick patients. The Medicines and Healthcare products Regulatory Agency (MHRA) of the UK says the following are at greater risk:

  • people above 60 years of age
  • those taking daily oral domperidone doses >30 mg,
  • patients taking QT-prolonging medicines or CYP3A4 inhibitors concurrently with domperidone.
  1. The manufacturer of the drug tells you not to take it while breastfeeding

Janssen Pharmaceuticals gives a different reason though, stating that it is not known whether the extremely low amount that gets ingested by the infant (maximum of 0.1% of the weight-adjusted dosage of the mother) is harmful or not.

  1. Chronic treatment using Domperidone in rodents led to increased breast tumors.

The International Breastfeeding Centre mentions a study that yielded this conclusion, but at the same time reminds mothers that breast cancer risk decreases with breastfeeding.

  1. It is recommended by lactation consultants and physicians for certain cases

Abbie Yabot, Certified Lactation Counselor, La Leche League Leader, and member of theAsianparent parent advisory board, uses Domperidone for moms she’s relactating (resuming direct breastfeeding after a long period of pause). Cases include adoptive mums (induced breastfeeding).

“There are side effects, so I work in partnership with their OB or Dr. Pat Kho,” says Abbie. Dr. Kho is an OB-GYN and IBCLC (International Board Certified Lactation Consultant®).

Dr. Kho assesses the patient carefully to see if it’s really a case of insufficient supply. “You really have to test and advise and counsel and observe.”

“You look at the mother’s breast and look at the baby. Does the mother have an illness, is she depressed, stressed, too anxious, or have resentment [towards the process]? You look at the breastfeeding relationship. If she’s breastfeeding only 3 times a day, then it really will not increase [even with the galactagogue],” explains Dr. Kho.

Success can be attained, but it comes with commitment and care. Mummy Donna Bondoc successfully used Domperidone when she was undergoing relactation, taking 3 tablets a day for 3 weeks, 2 tablets for 2 weeks 1 tablet for 1 week, as prescribed by her doctor.

This was done in conjunction with other techniques including: cross-nursing; getting full lactation massages and learning to do self-breast massages; drip-drop, cup, and spoon feedings to ditch formula and the bottle, and adjusting her diet and primary breastfeeding position.

Mommy Donna switched to the football hold.

The football hold was what Mummy Donna was advised to use as her primary breastfeeding position.

  1. The biggest risk is self-medication.

The US FDA reminds the public that no country has approved the drug for enhancing breast milk production.

“Because it’s easier to take the pill than increasing breastfeeding and pumping, or talking to a lactation consultant and trying other techniques,” Dr. Kho points out, “some women choose to take the drug without a proper prescription.”

“Domperidone is most likely safe for use,” she continues, “but you can’t just take it left and right. It’s still a drug, so some people may have an allergic reaction. We have to make sure they understand that [increasing milk supply is] an off-label indication and explain to them what the risks and benefits of taking it are.”

Women who self-medicate are at risk especially when they are prescribed another QT-prolonging medicine on top of taking Domperidone. Something as simple as an antibiotic for UTI or an antidepressant for postpartum depression taken with it, could put the mother at extremely high risk for arrhythmias.

  1. This controversial coin still has two sides.

As per the Medical Journal of Australia Insights:

The benefits of breastfeeding — including reducing infant morbidity and mortality, and reducing the incidence of certain cancers among mothers — could “greatly outweigh what amounts to, at this point in time, largely theoretical* risk associated with the use of domperidone as a galactagogue”.

*Since studies showed that the increased risk of sudden cardiac death was observed in men over 60, the risk for women below 60 would be “negligible”.

  1. It might not even work.

“I prescribe it in conjunction with other techniques. Taking galactagogues is not the primary method to increase milk supply,” says Dr. Kho.

She cites an example: “If the mother is taking Domperidone but is not increasing her breastfeeding and there’s still a problem with the latch, then even taking the galactagogue will not increase her milk supply,” says Dr. Kho. “And she might think that she’s a hopeless case because she already took the galactagogue but still didn’t increase supply.”

  1. There are other side effects.

The Women and Newborn Health Service (WNHS) of Western Australia lists the following as ‘adverse effects’:

  • dry mouth
  • headache
  • abdominal cramps
  • rash
  • insomnia
  • dizziness
  • palpitations
  • fainting
  • seizures
domperidone risks breastfeeding

If you have a blocked duct, nurse your baby more frequently on the affected side.

The Verdict

There are many other ways to increase breast milk supply that do not come with this many warnings. The number one tip is shared by Abbie:

“The best way to increase your milk supply, is increasing baby’s latch. The more that you express, the more you breastfeed your baby, the more milk you’ll have.” 

She also mentions that “there’s such a thing in nutrition as expanding and contracting foods. In layman’s terms, we know these as healthy and junk foods. The more healthy food you consume, like vegetables, the more milk you’ll produce.”

“It follows the law of supply and demand,” adds Bing. “If the breast is not empty and there is no stimulation, the body will not produce milk. Even if you take all the galactagogues available in the market, it’s never a guarantee that that will work.”

“Direct feeding done properly and efficiently is the key to maintaining milk supply. If direct feeding is not possible, drawing out milk by hand expression is the best method. This is a skill that every breastfeeding mother should learn.”

Whether direct-feeding or pumping, sneaking in more latch time, learning to hand-express, eating more vegetables, and trying other galactagogues like malunggay and fenugreek, are safer ways to increase breast milk supply.

Domperidone should be viewed as a last resort and discussed with both a medical professional and a certified lactation consultant prior to use. As the WNHS puts it, Domperidone is “prescribed when other methods of stimulating breastmilk production have proved ineffective.”

Again, the biggest risk lies in self-medication.

While the Pharmacovigilance Risk Assessment Committee of the European Medicines Agency has restricted use to 10mg thrice a day for a maximum of a week, Professor Peter Hartmann, of the University of WA Human Lactation Research Group says that maternal blood prolactin levels should be measured to to even just decide whether or not it should be used by a lactating mother.

However, these prolactin levels are “notoriously difficult to interpret” as per Associate Professor Wendy Brodribb of the Discipline of General Practice at the University of Queensland.

The safety, health, and well-being of both mother and child should be considered in this decision, which is again, to be made with the counsel of one’s doctor and certified lactation consultant.

This article is republished with permission from theAsianparent Philippines