Domperidone

Domperidone – Information for Breastfeeding Parents

Domperidone (Motilium) increases breastmilk production by increasing prolactin secretion from the pituitary gland (prolactin is a hormone which stimulates milk production). Domperidone is generally used to treat gastroesophageal reflux disease (GERD).

It has not been released in Canada for increasing milk supply, but this does not mean it cannot be prescribed for this reason. There are many studies that show that domperidone works to increase milk supply and is generally very safe to use.

Metoclopramide (Maxeran, Reglan) has also been used to increase milk supply, but it has frequent and unpleasant side effects (like fatigue, irritability, and depression). A serious, permanent side effect of metoclopramide is tardive dyskinesia, which is irreversible and has resulted in the Center for Disease Control in the US to publish a “black box warning” about its use. Domperidone has fewer side effects and is better tolerated by most people – this is because it does not enter the brain in significant amounts.

Note, even if you have “enough milk”, increasing the milk supply also increases the flow of milk. This is helpful for many situations, including sore nipples, fussiness at the breast, and refusing to latch. Why does domperidone help with sore nipples even if you have enough milk? Domperidone increases the flow of milk to the baby and increased flow will frequently improve the baby’s latch.

One of the most common reasons we recommend domperidone is for the problem of late onset decreasing milk supply and flow.

In general, domperidone should not be the only approach to address breastfeeding challenges. It should be used along with other strategies to increase milk supply and flow of milk and improve the breastfeeding situation. See the other information sheets at www.ibconline.ca, including “Protocol to Increase Breastmilk Intake” and “Late Onset Decreased Milk Supply or Flow”.

Using Domperidone

Generally, we start with 30 mg (three 10 mg tablets) three times per day – a total of 9 tablets per day. In some situations we will go as high as 40 mg four times per day (or, for convenience, 60 mg once per day and 50 mg twice per day). The pharmacist may instruct you to take each does 30 minutes before eating, but that recommendation is for its use for digestive problems.

Taking domperidone on an empty stomach does allow it to be better absorbed, but it is not necessary to do this for it to work to increase breastmilk production. Spread the doses out throughout the day and take it when it is most convenient for you. Mothers do not have time to make sure they take the domperidone at exactly such and such time.

After starting domperidone, it often takes at least three or four days before you notice any effect. It usually takes about two weeks to get a maximum effect, but some find it takes even longer.

It is important, for domperidone to work best, that, at the same time, you improve the baby’s latch, that you know how to know the baby drinks at the breast, to use breast compressions to increase the flow of milk to the baby, and to offer both breasts at each feeding. A baby who is not getting enough from the breast, will not refuse the second breast.

Side Effects of domperidone

As with all medications, side effects are possible. There is no such thing as a drug that has no side effects. However, in our clinical experience, side effects in the breastfeeding mother are very uncommon. Some mothers may experience headache (usually mild), dry mouth, abdominal cramps, weight gain/increased appetite, and alteration of menstrual periods (usually stopping them, if they have resumed; breakthrough bleeding is also possible). Most of those who experience side effects find they disappear after a few days to a week of starting the domperidone.

The amount of domperidone that gets into the breastmilk is very small and side effects in the baby should not be expected. Domperidone is sometimes given to babies with reflux and the amount they get through the milk is a very small percentage of what they would get if they were treated with domperidone directly.

How Long to Take Domperidone

As a general recommendation, continue taking domperidone until your baby is well established on solid foods. Some people continue domperidone for many months and some beyond a year. Worldwide experience with domperidone over at least 40 years suggests that long-term side effects are uncommon.

The one therapeutic exception to taking the domperidone until the baby is well established on solids is when we use it for the baby who not latching on and the mother already has a very good milk supply. Once the baby is well latched on and drinking well at the breast, the mother can try stopping the domperidone after the baby has consistently latched on well and drinking well for at least a week. Even in this situation, weaning off the domperidone should not be abrupt, but slowly reducing the dose over a week or two.

Stopping Domperidone

When you are ready to stop taking domperidone, you should wean off it gradually. This is to prevent a possibly significant drop in your milk supply and side-effects (like anxiety and loss of appetite, sleepless ness) that may occur if domperidone is stopped suddenly, especially if you have been on domperidone for several months.

To wean from domperidone, decrease your daily dose by one tablet per day per week (so, for example, if you are taking 30 mg three times per day, or nine tablets per day, you would first decrease to eight tablets per day). After seven days, if you see no decrease in your milk supply, decrease the daily dose by one tablet again. Continue in this way until you have completely stopped the medication.

If, at any point during the weaning process, you notice your milk supply decreasing significantly or your previous breastfeeding problems (or new ones) arise, return to the previous effective dose. Try resuming the weaning process again after a couple of weeks.

You may hear about domperidone:

In 2004, the Federal Drug Administration (FDA) in the United States put out a warning against using domperidone because of possible heart-related side effects. However, these side effects occurred only when the drug was given intravenously to otherwise very sick patients, taking many other drugs.

In 2012, Health Canada endorsed a warning put forth by the company who manufacturers domperidone. This warning was about oral doses higher than 30 mg per day and the risk of heart-related side effects. However, the research cited to support this warning involved patients with an average age of over 70 years old, many of whom had pre-existing health conditions.

These warnings do not apply to the population to whom we prescribe domperidone (typically younger, healthy women) and we have continued to prescribe it to breastfeeding parents as we have for more than 30 years. We have treated thousands of people with domperidone and we are not aware of any one of them experiencing heart-related side effects due to domperidone. Also, as of 2015, Health Canada had never received any reports of serious heart-related adverse effects in anyone of childbearing age taking domperidone.

Domperidone and the internet (Please do not go to the internet for information on domperidone. Naturally you will, so please read this)

The first note is followed by the section on the internet that is called “People also ask” which, we believe, without proof, is where non-professionals (and professionals too, actually) would go first. This section “People also ask” seems always in the prominent second position. And the first question that comes up visible even if you have not clicked it yet, is:

“Why is domperidone banned in US? Answer: Domperidone has been banned in the United States for years because of fatal cardiac arrhythmias among cancer patients who had been prescribed the drug to prevent nausea and vomiting.”

Well, given the attitude of many health professionals “Better a live formula feeding mother than a dead breastfeeding mother”, plus the mother’s (or her family’s) reading of this response, it is not surprising that some of our patients have been ready, even enthusiastic, to start domperidone at the clinic, but decide not to take it after “doing research”. The only thing that people read and sticks in their mind is “fatal cardiac arrhythmias”.

What the answer does not clarify is that the decision in the US to “ban” domperidone is based on deaths in cancer patients (the answer mentions this) who were receiving extremely high doses of domperidone intravenously every few hours, typically a single intravenous domperidone dose that we would prescribe for an entire 24 hour day for a breastfeeding mother (the internet answer does not mention the extremely high doses the cancer patients were receiving). Furthermore, it needs to be emphasized that only about 13-17% of an oral dose of domperidone is absorbed by the person taking domperidone as compared to 100% of a dose given intravenously. Thus, the situation of oral use of domperidone is not the same as large intravenous doses. Furthermore, many drugs used for treatment of cancer affect the cardiac rhythm, even in the absence of the patient receiving domperidone, and may cause cardiac arrest by decreasing or increasing the level of potassium in the blood.

Questions or concerns? Email Dr. Jack Newman (read the page carefully, and answer the listed questions).

Make an appointment at the Newman Breastfeeding Clinic.

The information presented here is general and not a substitute for personalized treatment from an International Board Certified Lactation Consultant (IBCLC) or other qualified medical professionals. This information sheet may be copied and distributed without further permission on the condition that it is not used in any context that violates the WHO International Code on the Marketing of Breastmilk Substitutes (1981) and subsequent World Health Assembly resolutions. If you don’t know what this means, please email us to ask!