Domperidone in the management of breast feeding (insufficient milk supply)

Domperidone in the management of breast feeding (insufficient milk supply)

• evidence for the use of domperidone in the management of insufficient milk supply during breast feeding shows a moderate short-term effect on expressed breast milk volume, increasing by around 86 to 245mL per day (1)
  • is less evidence evaluating domperidone in mothers feeding term infants
  • data available from 4 small studies on the excretion of domperidone into breastmilk are somewhat inconsistent, but infants would probably receive less than 0.1% of the maternal weight-adjusted dosage, even at high maternal doses (2)
• starting domperidone
  • domperidone was started between days 1 and 33 post-delivery
    • may be effective after this point, but there is no good evidence to support this
• dose of domperidone in the management of insufficient milk supply
  • should be prescribed at a dose of 10mg three times daily
    • higher than this should not be used
• duration of treatment
  • domperidone should be prescribed for 7 days and then reviewed
  • duration of treatment for 7 days is in line with the maximum treatment duration for the licensed indication (nausea and vomiting), due to the increased risk of cardiac events (particularly in certain populations), and potential for psychiatric withdrawal effects
  • whether to continue domperidone for longer than 7 days is a clinical decision after considering the evidence and potential increased risks
• stopping treatment and maintaining milk supply
  • not known whether stopping treatment with a galactagogue suddenly or gradually is better for maintaining milk supply
  • if milk supply reduces after stopping domperidone and improves on restarting again, gradually decrease to the lowest effective dose and attempt discontinuation again
  • gradual withdrawal may also help reduce concerns about discontinuation
• withdrawal symptoms after stopping domperidone
  • small number of case reports suggest withdrawal symptoms occur when domperidone is discontinued either suddenly or gradually. In all cases, either prolonged use (up to 10 months) or higher than recommended doses (up to 160mg daily) were used.
  • symptoms of withdrawal include:
    • insomnia
    • anxiety
    • headaches
    • palpitations
    • gastro-intestinal disturbances and depression
  • re-emergence of previous mental health conditions has been reported
  • if suspected withdrawal symptoms occur, increase the dose of domperidone back to a level that does not produce symptoms, and restart withdrawal more slowly
• risk of cardiac events
  • domperidone can cause a small increased risk of serious cardiac events, including certain types of arrhythmias, especially when used in high doses, for longer periods, or when additional risk factors are present
  • patients at higher risk of cardiac side effects include:
    • cardiac disease
    • severe liver problems
    • electrolyte imbalances
    • or taking medicines affecting the QT interval or which interact with domperidone
  • most breastfeeding women are relatively young and healthy and their baseline risk of cardiac events is very low
  • domperidone can be considered if a woman has no additional cardiac or medical risk factors, and is not taking medication that interacts with domperidone or affect the QT interval
  • however, if risk factors are present, then ECG monitoring may be required, or an alternative considered. Contact UKDILAS for alternative galactagogue use
• infant risk
  • cardiac events in the infant have not been reported after domperidone exposure via breast milk
  • if the infant has cardiac disease, severe liver disease or is receiving medicines which may be a problem, then domperidone use in the mother is best avoided. Contact UKDILAS for alternative galactagogue use
• domperidone levels in breast milk
  • very limited information shows domperidone passes into breast milk in negligible amounts (less than 0.5% of the maternal weight-adjusted dose), even with high dose, long term therapy (1)
  • note also that there is a very low risk of accumulation in the infant and its low oral bioavailability will limit the amount absorbed from the breast milk
• monitoring the infant
  • no serious side-effects have been reported in infants exposed to domperidone via breast milk
  • as a precaution, monitor for gastro-intestinal disturbances, or signs of dry mouth, such as difficulty feeding (1)
  • is no evidence that domperidone via breast milk can cause significant ECG changes in the infant, infant ECG monitoring is not routinely required
• ongoing support
  • ongoing lactation support will be necessary during treatment with domperidone. Regular review is needed if domperidone is used beyond 7 days

Reference:

1. NHS Speclialist Pharmacy Service (June 21st 2024). Using domperidone for low milk supply
2. Drugs and Lactation Database (LactMed®) [Internet]. Bethesda (MD): National Institute of Child Health and Human Development; 2006-. Domperidone. [Updated 2024 May 15]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK501371/