NDC Clinical Guidelines Induction of Lactation Part 3. Does domperidone improve breastmilk volumes in non-puerperal induction of lactation?
NDC Clinical Guidelines Induction of Lactation: Use of domperidone as part of mammary gland preparation for induction of lactation is biologically plausible
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The Newmann Goldfarb protocol recommends commencing domperidone at the same time as hormonal preparation for non-puerperal induction of lactation, up to six months prior to the arrival of the baby and continuing until a substantial breastmilk supply has resulted or the non-puerperal lactating parent is weaning the baby.
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The Newman Goldfarb recommendation of 20 mg four times daily also lacks an evidence-base, and increases the risk of side-effects. You can find out about domoperidone's side-effects here.
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Domperidone 10 mg three times daily has been shown to be effective as a galactogogue in mothers of preterm infants. There is no evidence to support 20 mg three times daily, although this is the dose I often prescribe.
Theoretical background to the use of domperidone from commencement of hormonal therapy
In a 1996 Professor Peter Hartmann concluded that prolactin is necessary for the secretion of milk by the cells of the alveoli. The level of prolactin in the blood increases markedly during pregnancy, and stimulates the growth and development of the mammary tissue, in preparation for the production of milk. However, milk is not secreted then, because progesterone and oestrogen, the hormones of pregnancy, block this action of prolactin. After delivery, levels of progesterone and oestrogen fall rapidly, prolactin is no longer blocked, and milk secretion begins.
For this reason, NGP concludes that long-term use of domperidone will contribute to the development of glandular tissue in the non-puerperal breast, although this is hypothetical only.
Forty-five percent of breastfeeding Australians using domperidone reported side-effects, including weight gain, headache, fatigue, irritability, and depression. If a patient wishing to induce lactation non-puerperally is experiencing side-effects from domperidone, that patient may decide to cease domperidone and re-commence it some time closer to the cessation of hormonal therapy e.g. one month prior to cessation of hormonal treatment.
Domperidone has been shown to increase breast milk production in the breasts of mothers of prematurely born infants, whose breasts have not have not had opportunity to fully mature. Because of this finding, the use of domperidone to aid in breast preparation for induced lactation is biologically plausible. However, there is no evidence to show the domperidone improves breastmilk volumes in induction of lactation. The most important factor in induction of lactation is nipple and breast stimulation.
Plasma prolactin levels do not correlate with milk volume or rate of milk synthesis in mothers of term infants
| Time frame | Baseline prolactin levels ng/ml |
|---|---|
| Non-pregnant | 10 |
| Peak at birth | 200 |
| 10-90 days post-birth | 60-110 |
| 3-6 months post-birth | 50-100 |
| 6 months + post-birth | 30-40 |
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Prolactin levels rise in a pulse after nipple stimulation and suckling, peaking about half an hour after the baby starts to suckle.
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Prolactin secretion varies with the circadian rhythm, resulting in serum levels being two or three times higher at night than during the day (including when not breastfeeding), peaking between two and six in the morning. There is no good physiological rationale to the belief that night-time breastfeeds increase milk production because of the effect of night-time breastfeeds on prolactin levels. It is more likely that long periods overnight without milk removal are responsible for decreased milk production if a woman isn't breastfeeding during the night, due to raised intra-alveolar pressures. You can find out about downregulation of milk secretion here.
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Baseline and peak levels are highly variable between women and do not correlate with a woman’s milk volumes or rate of milk synthesis.
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Frequent and flexible breastfeeds aren't likely to result in upregulation of milk secretion because of stimulation of prolactin and oxytocin. You can find out about the mechanisms more likely to underlie the upregulation of milk secretion here.
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Women with low breastmilk supply don’t usually have low prolactin levels.
Taper the dose of domperidone prior to complete cessation
If domperidone is used, it's important to taper the dose of domperidone slowly when it's time to cease, and cessation can result in insomnia, anxiety, headaches, palpitations, gastro-intestinal disturbances, depression, or recurrence of any previous psychiatric symptoms
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More about domperidone use in lactation, including side-effects and relevant citations, is found here.
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Information about ensuring patient safety when commencing domperidone is found in the NDC Resource Hub (domperidone safety check list).
Recommended resources
Research about induction of lactation in transgender patients
Induction of lactation: taking a history and why each question matters
Case report of preparation for induction of lactation in a cisgender woman (NDC Clinical Guidelines)
NDC Co-lactation Feeding Plan (to be adapted adapted)
Selected references
McBride GM, Stevenson R, Zizzo G, Rumbold AR, Amir LH, Keir AK, et al. Use and experience of galactogogues while breastfeeding among Australian women. Plos One. 2021;16(7):e0254049
Other references available here.
Hartmann PE, et al. Breast development and the control of milk synthesis. Food and Nutrition Bulletin. 1996;17(4):292–302.
