NDC Clinical Guidelines Induction of Lactation: Use of domperidone as part of mammary gland preparation for induction of lactation is biologically plausible

• The Newmann Goldfarb protocol (NGP) 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.

• 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.

• 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. You can find an article discussing why plasma prolactin levels don't correlate with milk volume or rate of milk synthesis in mothers of term infants here.

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

• More about domperidone use in lactation, including side-effects and relevant citations, is found here.

• Information about ensuring patient safety when commencing domperidone is found in the NDC Resource Hub (domperidone safety check list).

Recommended resources

Does domperidone increase breast milk production? Dr Pamela Douglas, The Medical Republic 2022

Plasma prolactin levels do not correlate with milk volume or rate of milk synthesis in mothers of term infants

Existing research about induction of lactation in transgender patients: for medical practitioners with special interest

Research about induction of lactation in transgender patients

When might non-puerperal induction of lactation be requested and what volumes of milk are realistic to expect?

Induction of lactation: taking a history and why each question matters

NDC Clinical Guidelines Induction of Lactation Part 1. The most reliable element in non-puerperal induction of lactation protocols is stimulation of the breasts and nipples + frequent flexible milk removal

NDC Clinical Guidelines Induction of Lactation Part 2. Do hormonal medications improve breastmilk volumes in non-puerperal induction of lactation?

Acknowledgement of the pioneering contribution made by the Newman Goldfarb Protocols for Induction of Lactation - and why the NDC Clinical Guideline for Induction of Lactation has differences

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

Hartmann PE, et al. Breast development and the control of milk synthesis. Food and Nutrition Bulletin. 1996;17(4):292–302.

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.