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Domperidone, Getting Started
by Jack Newman, MD, FRCPC

Introduction

Domperidone (MotiliumTM) is a drug that has, as a side effect, the increase 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 (PrepulsidTM). (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 (MaxeranT, ReglanT), is also known to increase milk production, but it has frequent side effects which have made its use for many breastfeeding 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, which 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 Intake of Breastmilk by the Baby). What can be done?

  1. Do as much skin to skin as possible with the baby, during and in between feedings. See handout: Skin to Skin Contact.

  2. Correct the baby's latch so that the baby can best obtain the milk 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" (See the video clips on our website www.drjacknewman.com).

  3. Use breast compressions to increase the intake of milk. (See handout Breast Compression).

  4. If you are breastfeeding exclusively, try expressing your milk after the feedings. A few minutes of hand expression after the feedings may be very effective to increase the milk supply. Some mothers may wish to use a hospital grade pump for 10-15 minutes after feedings-this may be very effective for some and not at all for others. Do what you can. A mother exhausted from pumping is probably no further ahead with milk production.

  5. Correct sucking problems, stopping the use of artificial nipples (handout Lactation Aid, and Finger and Cup Feeding) and other stratagems.

Using domperidone for increasing milk production:

Domperidone works particularly well to increase milk production under the following circumstances:

  1. 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 (not putting the baby to the breast early enough, no true kangaroo mother care, etc), but domperidone generally brings the amount of milk pumped back to where it was or even to higher levels.

  2. When a mother has a decrease in milk supply, often associated with the use of birth control pills. Avoid estrogen containing, or even progesterone only birth control pills or progesterone releasing intrauterine devices (Mirena) while breastfeeding. See the handout, Slow Weight Gain Following Early Good Weight Gain for other reasons milk supply might decrease and fix what can be fixed.

Domperidone still works, but often less dramatically when:

  1. The mother is pumping for a sick or premature baby but has not managed to develop a full milk supply.
  2. The mother is trying to develop a full milk supply while breastfeeding an adopted baby.
  3. 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 after a few days or when the dose was reduced (probably the most common side effect)

  1. Abdominal Cramps
  2. Dry Mouth
  3. 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. Remember, this is a medication often given to babies for reflux.

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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). Many 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 breastfeeding adopted babies may have to take the drug much longer. People taking domperidone for stomach disorders often have been 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? see my book Dr. Jack Newman's Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA)

Handout #19a. Domperidone, Getting Started. Revised May 2008
Written and Revised by Jack Newman, MD, FRCPC 1995-2005
Revised by Edith Kernerman, IBCLC, and Jack Newman, MD, FRCPC © 2008

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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