Effect of Domperidone on Breast Milk Production in Mothers of Sick Neonates: A Randomized, Double-Blinded, Placebo-Controlled Trial

Analysis of a Pharmacy Developed, Outpatient Lactation Consultant Initiated Domperidone Programme

BACKGROUND

Domperidone is a commonly prescribed galactagogue used off-label for lactation insufficiency. Prescriber unfamiliarity or safety concerns can lead to therapeutic delay and potential early breastfeeding discontinuation. To facilitate access, the study site pharmacy department developed a Structured Administration and Supply Arrangement (SASA) for International Board-Certified Lactation Consultants (IBCLC) to screen and initiate domperidone using a checklist.

MATERIAL

To validate a domperidone screening tool via analysis of its use and compliance, together with a staff satisfaction survey.

METHODS

Records were extracted from the REDCap® database for women with documented domperidone supply between 06/05/2022 and 27/01/2023 and reviewed with medical records. A staff survey was distributed assessing compliance and attitudes towards the SASA.

RESULTS

Records of supply revealed that 34% (17/50) of patients were referred to a physician, revealing a discrepancy between database documentation and checklists, as no referrals were documented. Overall staff satisfaction with the SASA was rated 4.6 out of 5. 77.7% (7/9) felt confident counselling and supplying domperidone with the SASA in place. 88.9% (8/9) felt confident using the checklist to identify the appropriateness of therapy and referral to a physician.

CONCLUSIONS

The system in place allows the IBCLCs to initiate and supply domperidone in a timely manner to breastfeeding mothers with lactation insufficiency. The support tools, including domperidone SASA, REDCap® documentation database and the checklist domperidone as a Galactagogue Checklist, can be greatly appreciated by the LCs. Continued discussion with IBCLCs to refine and improve the SASA and associated education package will result in more consistent compliance.

Longitudinal trends in domperidone dispensing to mothers of very preterm infants and its association with breast milk feeding at infant discharge: a retrospective study

OBJECTIVE

This study aims: (a) to evaluate patterns of domperidone dispensing to mothers of very preterm (<32 weeks gestation) infants born before and after 2014 when international recommendations were made to limit its use and (b) to examine characteristics associated with domperidone dispensing and impacts on breast milk feeding rates at infant hospital discharge.

DESIGN

Retrospective audit using linked electronic medical records and hospital pharmacy records.

SETTING

Tertiary-referral neonatal intensive care unit at the Women's and Children's Hospital in South Australia.

PATIENTS

Mothers of preterm infants admitted to neonatal intensive care from January 2004 to December 2018.

MAIN OUTCOME MEASURES

Rate of domperidone dispensing compared pre-2014 and post-2014 recommendations using interrupted time series analyses, and breast milk feeding rates at infant discharge based on domperidone treatment status, adjusted for other factors known to influence breast milk production.

RESULTS

Overall, domperidone was dispensed to 691 (41%) of 1688 mothers. Prior to 2014 recommendations, the proportion of women dispensed domperidone was stable. Following the recommendations, there was a significant reduction in trend (-2.55% per half year, 95% CI -4.57% to -0.53%;), reflecting less domperidone dispensing.Breast milk feeding rates at discharge remained consistently lower in infants of women dispensed domperidone than those who were not (adjusted OR 0.58, 95% CI 0.45 to 0.75).

CONCLUSION

Domperidone dispensing in mothers of hospitalised very preterm infants has declined over time following international regulatory warnings. Breast milk feeding rates remain lower in mothers prescribed domperidone, suggesting further research is needed to optimise lactation support for mothers of very preterm infants.

Providing domperidone throughout lactation enhances sow lactation performance

The goal of this project was to determine the effects of domperidone given throughout lactation on hormonal and metabolic status, lactational performance, and gene expression in mammary epithelial cells of sows. Second parity sows were divided in two treatment groups: 1) daily intramuscular injections with canola oil (Control, CTL, n = 24), or 2) daily intramuscular injections with 0.5 mg/kg body weight (BW) of domperidone (DOMP, n = 23). Injections were given at 08h05 starting the day after farrowing until weaning. Over the first 4 d of treatment, DOMP sows also received 0.5 mg/kg BW of domperidone per os twice daily, whereas CTL sows were fed the vehicle. Litter size was standardized to 11 ± 1 within 24 h of birth and piglets were weighed at birth, 24 h postpartum, and on days 7, 22 (weaning on day 23), 35, and 56. Sow feed intake was recorded daily. Representative milk samples were obtained aseptically on day 21 of lactation from 15 sows per treatment for compositional analyses and milk fat globules were used to measure mRNA abundances of various genes. Jugular blood samples were obtained from all sows on days 2, 8, 16, and 23 of lactation to measure concentrations of prolactin, insulin-like growth factor-1 (IGF-1), leptin, adiponectin, insulin, glucose, urea, and free fatty acids (FFA). Concentrations of prolactin (P < 0.001) and FFA (P < 0.01) were increased in DOMP compared with CTL sows, whereas concentrations of insulin were decreased (P < 0.05). Urea concentrations were increased by treatment (P < 0.05) on days 16 and 23 of lactation, and those of IGF-1 were increased (P < 0.01) on day 16. Piglets from DOMP sows were heavier than those from CTL sows on day 22 (P < 0.01). Milk composition was unaffected by treatment. The mRNA abundance in milk fat globules for casein beta and whey acidic protein were lower (P ≤ 0.05) in DOMP than CTL sows. The long form of the prolactin receptor and the signal transducer and activator of transcription 5A mRNA abundances tended to be lower (P < 0.10) in DOMP than CTL sows. In conclusion, hyperprolactinemia induced by domperidone during lactation affected the endocrine and metabolite status of sows and stimulated growth of their suckling piglets.

Efficacy and Safety of Domperidone and Metoclopramide in Breastfeeding: A Systematic Review and Meta-Analysis

Objectives: To evaluate the efficacy and safety of domperidone and metoclopramide used by breastfeeding women. Methods: A systematic literature search retrieved citations from PubMed, Embase, The Cochrane Library, Medline, EBSCO, Web of Science, ClinicalTrials.gov (from inception to January, 2021) and bibliographies of known articles. Randomized controlled trials exploring the effects of domperidone and metoclopramide in breastfeeding women with term and preterm infants experiencing adequate or low milk supply were identified. Human milk volume and maternal side effects were presented as mean difference (MD) or relative risks (RR) with 95% confidence intervals (CI). Results: Sixteen trials involving 729 women were included in the qualitative analysis and 14 trials involving 607 women were included in the meta-analysis. In mothers of preterm infants with low milk supply, domperidone demonstrated a significant increase in daily human milk volume (MD = 90.53 mL/day, 95% CI [65.42 to 115.64], I² = 9%). However, metoclopramide did not show significant difference in daily human milk volume in women with preterm infants (MD = -1.14 mL/day, 95% CI [-31.42 to 29.14], I² = 0%). No differences in maternal side effects were noted with domperidone (RR = 1.20, 95% CI [0.74 to 1.97], I² = 0%) or metoclopramide (RR = 1.05, 95% CI [0.52 to 2.11], I² = 27%) in women with preterm infants. Regarding the women with term infants, there were insufficient data in the current review. Conclusions: Domperidone can be used to treat low milk supply in women with preterm infants without significant side effects based on the current review. More evidence exploring the efficacy and safety of domperidone and metoclopramide are still needed for breastfeeding women in the future.