Several factors can impact breast milk supply with common factors including low frequency of breastfeeding, wrong latching by a baby, late start of breastfeeding, use of formula alongside breastfeeding and some drugs. Drug therapy to increase milk production is usually considered when insufficient milk is produced despite appropriate lactation support (Grzeskowiak et al, 2018). Today I will review the use of domperidone in breastfeeding. One of the uncommon side effects of domperidone is galactorrhoea (excessive milk production), which lead to unlicensed use of domperidone in breastfeeding to increase the production of the milk. I will review several areas considering domperidone in breastfeeding. Summary of the post:
- What is domperidone
- Can you get domperidone over the counter?
- How domperidone increase milk production?
- Domperidone in breastfeeding: Can domperidone increase milk supply?
- Domperidone dosage in breastfeeding
- Domperidone: possible side effects
- Is domperidone excreted in breastmilk?
- Can you get domperidone prescribed on the NHS?
- How much does domperidone cost (private prescription cost)?
What is domperidone?
Domperidone is prescription-only medication (POM) licensed in the UK for the symptoms of nausea and vomiting. Domperidone is also known as Motilium, which is a branded name of domperidone. Both generic version and Motilium contains the same amount of the active drug – 10mg of domperidone per tablet.
Can you get domperidone over the counter?
No. Domperidone is a prescription-only medication and requires a qualified prescriber, for example, a doctor to issue a prescription for the drug. In the past, domperidone used to be available from the pharmacy as over the counter medication, sold as Motilium 10 and Motilium instants. In 2014, domperidone was reclassified as prescription-only medicine. Consequently, all pharmacy-only products were recalled.
The reason behind reclassification of domperidone was a small increased risk of serious cardiac side effects (for example, QTc prolongation, torsade de pointes, serious ventricular arrhythmia, and sudden cardiac death) when this drug is taken.
Domperidone in breastfeeding: how domperidone increase milk supply?
Domperidone is one of the most commonly used drugs when an increase in breastmilk supply is needed. As stated in the introductory paragraph, one of uncommon side effect for domperidone use is increased milk production (galactorrhoea) alongside other uncommon side effects such as breast pain and breast tenderness. Uncommon side effects happen infrequently with estimated patients between >= 1 in 1000 and < 1/100.
Domperidone is classified as a dopamine receptor antagonist, which in plain language means that it stops dopamine (a type of neurotransmitter) from working. Dopamine, which is released in one part of the brain suppresses the release of a hormone called prolactin, which promotes lactation (milk production). Since domperidone stops dopamine from working, more prolactin is secreted in the brain. This stimulates milk production.
During pregnancy, prolactin levels increase, causing breasts to grow (increase the size of the mammary glands) and stimulates milk production.
Domperidone in breastfeeding: can domperidone increase milk production?
Several studies investigated the use of domperidone in breastfeeding. The best available evidence comes from a systemic review of those studies. The systemic review compares large data from different studies.
Grzeskowiak et al. reviewed five clinical trials on the effect of domperidone on milk production. Mothers included in trials expressed milk for their preterm infants (<37 weeks’ gestation). In total, 194 mothers took part in clinical trials (Grzeskowiak et al., 2018).
The main finding from this review:
- One average mother who took domperidone increased daily breast milk volume by 88.3ml.
- Short-term use of domperidone increased amount of milk produced in mothers of preterm infants.
- Mothers tolerated domperidone well, with no side effect reported (no report of prolonged QTc syndrome)
- Adverse side effects experienced by neonates were gathered in 3 out of 5 studies. Only one study confirmed adverse events in neonates. In one study, 91 infants were investigated for possible QTc syndrome at the start of the trial and 76 infants at the end of it. Only five infants were found to have a QTc interval >500ms. None of the infants were clinically symptomatic, and no medical intervention or treatment was required.
Cochrane produced a newer review recently to investigate the effect of milk boosters (drugs, herbal products or foods) on milk production in breastfeeding mothers of healthy infants born at term (Foong et al., 2020).
Cochrane covered 41 studies with a total of 3005 mothers and 3006 infants. Nine reviews compare pharmacological (drug) approach to increase milk supply. Domperidone was one of the drugs investigated alongside other galactagogues (medicines or foods that increase the production of the milk) including metoclopramide, sulpiride, thyrotropin-releasing hormone.
Some findings from this large meta-analysis (review of different studies / clinical trials):
- Overall, the evidence behind all studies was graded as low or very low
- Three studies compared metoclopramide, domperidone and sulpiride on the volume of milk produced
- Based on the above studies it was concluded that pharmacological (drug) milk booster such as domperidone, may increase milk volume in breastfeeding mothers (an average increase in milk production was 63ml, range from 26ml to 102ml). The evidence was marked as low quality with only 152 participants taking part in this study.
- Cochrane concluded that due to the low quality of evidence, it is unknown if galactagogues have any effect on mothers who breastfed at 3,4 and 6 months.
Can you get domperidone prescribed on NHS?
National guideline on breastfeeding recommends several measures regarding breastfeeding problems. In the first instance, a woman with breastfeeding problems needs to be offered an appropriate training by a health visitor or breastfeeding specialist and written information on infant positioning and attachment in breastfeeding together with many other recommendations.
There are plenty of educational videos on breastfeeding available on YouTube. A good attachment will help a baby get more milk and make breastfeeding more comfortable. Global Health Media Project produced an excellent video on attachment and breastfeeding. Follow this link to see it. Although intended for mother is developing world, this video offers some very useful tips for any mother.
Breastfeeding mothers may be examined to exclude other underlying problems, such as blocked duct, galactocele (presence of a milk cyst) or ductal infection (bacterial or fungal).
Domperidone can be considered as off-licensed treatment to help improve milk supply, possibly after a referral to an endocrinologist is made (NICE, 2017).
It can be concluded that an NHS doctor can prescribe domperidone in breastfeeding to increase the volume of milk produced, however, it is not the first-line recommendation.
Domperidone in breastfeeding: possible side effects
The most common side effect associated with domperidone use is dry mouth. Some possible, uncommon side effects can be experienced when domperidone is taken including:
- Loss of interest in sex
- Sleepiness/feeling dizzy
- Rash / hives / itchiness
- Painful breast
- Milk discharge from breasts
- Feeling weak
Although dizziness and sleepiness are uncommon side effects, patients are advised not to drive or operate machinery should they experience confusion, drowsiness, or lack of control.
Is domperidone excreted in breastmilk?
Domperidone is excreted in human milk, with an estimated amount of less than 0.1% of the given dose. The risk of possible side effects cannot be excluded in infants who are breastfed.
What is the dose of domperidone in breastfeeding?
Use of domperidone in breastfeeding to increase milk production is an unlicensed indication. When used to prevent nausea and vomiting, the recommended daily dose is one tablet taken three times a day (10mg three times a day) with a maximum of three tablets in one day (maximum 30mg daily) – this is a standard dose for domperidone.
Mothers who took part in clinical trials discussed in this post in most cases were given one tablet three times a day.
- Domperidone tablets should not be taken for longer than seven days in a row without consulting a doctor.
- Domperidone should be taken before food (15-30 mins before a meal).
How much does domperidone cost?
Generic domperidone 10mg tablets:
- pack of 30 tablets £0.99
- pack of 100 tablets: £3.30
Motilium (branded domperidone 10mg tablets):
- pack of 30 tablets: £2.71
- pack of 100 tablets: £9.04
The above trade prices (prices: AHH Pharmaceuticals, October 2020) would only apply to patients who were prescribed domperidone on a private prescription. When a supply of a drug is made on a private prescription in a community pharmacy, customers cover the cost of medication supplied plus an additional dispensing fee (10%-20% on top of the drug cost) or a minimum charge, which varies between pharmacies.
Tesco Pharmacy is one of the cheapest pharmacies when it comes to dispensing private prescriptions. The minimum dispensing charge at Tesco Pharmacy is set at £2.00 (October 2020), patients can expect to pay £2.00 for a supply of generic domperidone (pack of 30 tablets). Please note that the prices of drug change regularly.
Domperidone is one of the first choices when drug therapy is considered due to relative safety to both mothers and new-born babies (Haase 2016; Winterfeld 2012). Perhaps as Cochrane Collaboration concluded, ‘an urgent’ randomised control trial is needed to assess the effectiveness of domperidone and other drugs in breastfeeding and impact on milk production.
Grzeskowiak LE, Smithers LG, Amir LH, Grivell RM. Domperidone for increasing breast milk volume in mothers expressing breast milk for their preterm infants: a systematic review and meta-analysis. BJOG. 2018 Oct;125(11):1371-1378. doi: 10.1111/1471-0528.15177. Epub 2018 Mar 27. PMID: 29469929. Available at: https://doi.org/10.1111/1471-0528.15177 Accessed on 14/10/2020
Foong SC, Tan ML, Foong WC, Marasco LA, Ho JJ, Ong JH. Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non-hospitalised term infants. Cochrane Database of Systematic Reviews 2020, Issue 5. Art. No.: CD011505. DOI: 10.1002/14651858.CD011505.pub2. Available at: https://doi.org/10.1002/14651858.CD011505.pub2 Accessed on 16/10/2020
Haase B, Taylor SN, Mauldin J, Johnson TS, Wagner CL. Domperidone for Treatment of Low Milk Supply in Breast Pump-Dependent Mothers of Hospitalized Premature Infants: A Clinical Protocol. J Hum Lact. 2016 May;32(2):373-81. doi: 10.1177/0890334416630539. Epub 2016 Feb 23. PMID: 26905341. Available at: https://doi.org/10.1177/0890334416630539 Accessed on 16/10/2020
NICE (2017). Breastfeeding problems. Available at: https://cks.nice.org.uk/topics/breastfeeding-problems/ Accessed on 16/10/2020
Winterfeld U, Meyer Y, Panchaud A, Einarson A. Management of deficient lactation in Switzerland and Canada: a survey of midwives’ current practices. Breastfeed Med. 2012 Aug;7:317-8. doi: 10.1089/bfm.2011.0092. Epub 2012 Jan 6. PMID: 22224508. Available at: https://doi.org/10.1089/bfm.2011.0092 Accessed on 16/10/2020