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 (Ga·làc·to·gouge : a medication that induces lactation) Dom Perignon and other fine wines and spirits have long been used as human fertility enhancers. 1,2 Domperidone, meanwhile, is quite fine as a lactation enhancer. Indeed, when deciding on which oral galactogogue to use for maternal lactation augmentation, choosing domperidone (Motilium®) over its cousin metoclopramide (Reglan®) is like choosing a '93 Château Mouton-Rothschild over a box of '03 Gallo rosé. 3,4 An easy choice for connoisseurs to make.Both domperidone and metoclopramide can increase pituitary prolactin secretion and can therefore boost a nursing mother's milk supply. Both are thus reasonable options when we consider adding drug therapy to self-care measures in order to help treat a mother's insufficient milk. Both can also boast published efficacy in mothers of term and premature infants. Domperidone has a number of advantages over metoclopramide. It doesn't cause central nervous system side effects, it transfers less freely into breast milk and its efficacy has been demonstrated in randomized, double blind, placebo-controlled trials. 5,6,7 Metoclopramide's efficacy, meanwhile, is largely based on case reports and open-label, observational studies. Both drugs have only been studied in small numbers of women and for limited periods. The two have never been compared head to head for the treatment of diminished milk supply. For a more complete analysis of the literature, the reader is referred to two recent reviews. 8,9The recommended dose of domperidone is 10-20 mg po tid-qid. Increase in milk production should be apparent by the 3rd to 4th day of treatment. Maximum effect may take 2-3 weeks and treatment may last up to several weeks as needed. Weaning or discontinuation can be attempted if breast-feeding becomes well established. Possible side effects include rash, headache, abdominal cramps and dry mouth. Domperidone's primary disadvantage is its restricted availability. Metoclopramide, while not FDA approved for lactation augmentation, is approved for other conditions including diabetic gastroparesis and GERD. It is thus available at any pharmacy. Domperidone is not FDA approved for any indication in the US. This is the result of a business and marketing decision by the pharmaceutical company which owns it. However, the drug is widely used and available in Canada, Mexico, Australia, Europe, and South Africa. Traveling to these countries, either in person or via the world wide web, is a possible option for mothers trying to locate domperidone. It is also available, with a prescription, from any US pharmacy willing to compound domperidone capsules from raw domperidone powder. A few pharmacies in San Diego can perform this service, as well as several reputable internet pharmacies throughout the US. See the San Diego County Breastfeeding Coalition web site for more information on locating domperidone (domperidone fact sheet). If obtaining and using domperidone is not an option, metoclopramide at a dose of 10 mg po tid is an alternative. Side effects include a ~0.2% to 1% risk of acute dystonic reactions and a ~10% risk of restlessness, drowsiness and fatigue. Metoclopramide can also cause mild to severe depression and should not be used in a patient with a history of depression. 10 Because of the side effect potential, duration of metoclopramide treatment for diminished milk supply is usually only 2-3 weeks. Onset of effect and expected response to therapy is the same as for domperidone. Although metoclopramide does pass into breast milk, it is considered safe to use during breastfeeding11 as the estimated daily dose an infant will receive from breast milk is only 1/8th the dose commonly given to infants for the treatment of reflux.One must temper their bubbly enthusiasm for the intoxicating appeal of domperidone, however, as there have only been a total of 24 women studied in clinical trials and these trials were conducted over only 5-10 days. Furthermore, medication is only an adjunct rather than a long-term solution to inadequate milk production. 12 Management of insufficient milk is centered on increasing the frequency and thoroughness of milk removal. 13Jason Sauberan PharmD
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