Sulpiride improves inadequate lactation

Evolutionary biological perspectives on current social issues of breastfeeding and weaning

Breastfeeding and weaning are actively studied from evolutionary, medical, and social research perspectives because of their close association with infant mortality, lifetime health, and human population dynamics. Each discipline benefits from an interdisciplinary exchange of knowledge regarding the bases, processes, and consequences of these phenomena. However, current social issues related to breastfeeding and weaning have received little attention from an evolutionary biology perspective. We address this gap by reviewing current social issues related to human breastfeeding and weaning in an evolutionary framework. This approach helps build a conceptual framework with the goal of better understanding ultimate causes of or influences on these current social issues. The six social issues reviewed here fall into three categories: the spatiotemporal constraints of breastfeeding, abuse of breast milk as valuable material, and mismatch in breastfeeding practices. Some of these issues have an evolutionary basis. We analyze the structure of these social issues and discuss their possible solutions in terms of extension of the trade-off theory in evolutionary biology. Our discussion on the current social issues in breastfeeding and weaning highlights the effectiveness of an approach rooted in evolutionary theory and biological anthropology.

Medicinal Mushroom Leucocalocybe mongolica Imai Extracts Improve Mammary Gland Differentiation in Lactating Rats via Regulating Protein Expression

Leucocalocybe mongolica is a known medicinal mushroom in China. It possesses many biological activities. This study investigated the effect of L. mongolica petroleum ether and water extracts (200, 500, and 1,000 mg/kg BW) on mammary gland differentiation during lactation. However, prolactin, growth hormone, progesterone, and estrogen levels were determined in serum by ELISA assay. Immunofluorescence, western blot, and real-time PCR were utilized to evaluate the expression levels of β-casein, α-Lactalbumin, prolactin receptor, progesterone receptor, and STAT-5a. The immunohistochemistry staining was used to detect the presence of steroid receptors. The results showed that petroleum ether and water extracts increased milk yield and milk content of calcium, total fat, total carbohydrate, and total protein. Prolactin and growth hormone levels were significantly upregulated in all treated groups compared with the control group. In contrast, progesterone and estrogen were downregulated. The high doses of petroleum ether and water extracts increased the expression levels of β-Cas, α-Lactalb, PRLR, PR, and STAT-5a. The observation of histological sections showed that the extracts induced higher mammary gland differentiation than the control group. This study is the first to use mushrooms as nutritional supplements to improve milk production and mammary gland differentiation during lactation.

Transfer of brotizolam, periciazine, and sulpiride in cord blood and breast milk, and alprazolam in breast milk: a case report

Background

A high prevalence of mental disorders including depression, anxiety, somatoform, and dissociative disorder is reported during pregnancy, however, information on the transfer of antipsychotics across the placenta and into breast milk is limited. We evaluated brotizolam, periciazine and sulpiride in cord blood, maternal serum, and breast milk, and alprazolam in breast milk.

Case presentation

A 38-year-old woman with dissociative disorder was treated with brotizolam, propericiazine, and sulpiride during pregnancy and lactation, and alprazolam during lactation. The drug concentration ratios for both cord blood and maternal serum were 33.3 and 61.5% for brotizolam and sulpiride, respectively, and periciazine (metabolite of propericiazine) was not detected in the cord blood. In breast milk, alprazolam (0.9 ng/mL), sulpiride (445.8 ng/mL), and periciazine (0.3 ng/mL) concentrations were noted at 7.5 h after the last dose on postpartum, whereas brotizolam was not detected. The relative infant doses via breast milk were 1.4, 2.7 and 0.02% of the maternal daily dose, respectively. The neonate had no congenital anomalies and did not experience any severe withdrawal symptoms after birth.

Conclusion

Use of brotizolam, propericiazine, and sulpiride during pregnancy and lactation, and use of alprazolam during lactation were acceptable in this case.

Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non-hospitalised term infants

BACKGROUND

Many women express concern about their ability to produce enough milk, and insufficient milk is frequently cited as the reason for supplementation and early termination of breastfeeding. When addressing this concern, it is important first to consider the influence of maternal and neonatal health, infant suck, proper latch, and feeding frequency on milk production, and that steps be taken to correct or compensate for any contributing issues. Oral galactagogues are substances that stimulate milk production. They may be pharmacological or non-pharmacological (natural). Natural galactagogues are usually botanical or other food agents. The choice between pharmacological or natural galactagogues is often influenced by familiarity and local customs. Evidence for the possible benefits and harms of galactagogues is important for making an informed decision on their use.

OBJECTIVES

To assess the effect of oral galactagogues for increasing milk production in non-hospitalised breastfeeding mother-term infant pairs.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Health Research and Development Network - Phillippines (HERDIN), Natural Products Alert (Napralert), the personal reference collection of author LM, and reference lists of retrieved studies (4 November 2019).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs (including published abstracts) comparing oral galactagogues with placebo, no treatment, or another oral galactagogue in mothers breastfeeding healthy term infants. We also included cluster-randomised trials but excluded cross-over trials.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. Two to four review authors independently selected the studies, assessed the risk of bias, extracted data for analysis and checked accuracy. Where necessary, we contacted the study authors for clarification.

MAIN RESULTS

Forty-one RCTs involving 3005 mothers and 3006 infants from at least 17 countries met the inclusion criteria. Studies were conducted either in hospitals immediately postpartum or in the community. There was considerable variation in mothers, particularly in parity and whether or not they had lactation insufficiency. Infants' ages at commencement of the studies ranged from newborn to 6 months. The overall certainty of evidence was low to very low because of high risk of biases (mainly due to lack of blinding), substantial clinical and statistical heterogeneity, and imprecision of measurements. Pharmacological galactagogues Nine studies compared a pharmacological galactagogue (domperidone, metoclopramide, sulpiride, thyrotropin-releasing hormone) with placebo or no treatment. The primary outcome of proportion of mothers who continued breastfeeding at 3, 4 and 6 months was not reported. Only one study (metoclopramide) reported on the outcome of infant weight, finding little or no difference (mean difference (MD) 23.0 grams, 95% confidence interval (CI) -47.71 to 93.71; 1 study, 20 participants; low-certainty evidence). Three studies (metoclopramide, domperidone, sulpiride) reported on milk volume, finding pharmacological galactagogues may increase milk volume (MD 63.82 mL, 95% CI 25.91 to 101.72; I² = 34%; 3 studies, 151 participants; low-certainty evidence). Subgroup analysis indicates there may be increased milk volume with each drug, but with varying CIs. There was limited reporting of adverse effects, none of which could be meta-analysed. Where reported, they were limited to minor complaints, such as tiredness, nausea, headache and dry mouth (very low-certainty evidence). No adverse effects were reported for infants. Natural galactagogues Twenty-seven studies compared natural oral galactagogues (banana flower, fennel, fenugreek, ginger, ixbut, levant cotton, moringa, palm dates, pork knuckle, shatavari, silymarin, torbangun leaves or other natural mixtures) with placebo or no treatment. One study (Mother's Milk Tea) reported breastfeeding rates at six months with a concluding statement of "no significant difference" (no data and no measure of significance provided, 60 participants, very low-certainty evidence). Three studies (fennel, fenugreek, moringa, mixed botanical tea) reported infant weight but could not be meta-analysed due to substantial clinical and statistical heterogeneity (I² = 60%, 275 participants, very low-certainty evidence). Subgroup analysis shows we are very uncertain whether fennel or fenugreek improves infant weight, whereas moringa and mixed botanical tea may increase infant weight compared to placebo. Thirteen studies (Bu Xue Sheng Ru, Chanbao, Cui Ru, banana flower, fenugreek, ginger, moringa, fenugreek, ginger and turmeric mix, ixbut, mixed botanical tea, Sheng Ru He Ji, silymarin, Xian Tong Ru, palm dates; 962 participants) reported on milk volume, but meta-analysis was not possible due to substantial heterogeneity (I² = 99%). The subgroup analysis for each intervention suggested either benefit or little or no difference (very low-certainty evidence). There was limited reporting of adverse effects, none of which could be meta-analysed. Where reported, they were limited to minor complaints such as mothers with urine that smelled like maple syrup and urticaria in infants (very low-certainty evidence). Galactagogue versus galactagogue Eight studies (Chanbao; Bue Xue Sheng Ru, domperidone, moringa, fenugreek, palm dates, torbangun, moloco, Mu Er Wu You, Kun Yuan Tong Ru) compared one oral galactagogue with another. We were unable to perform meta-analysis because there was only one small study for each match-up, so we do not know if one galactagogue is better than another for any outcome.

AUTHORS' CONCLUSIONS

Due to extremely limited, very low certainty evidence, we do not know whether galactagogues have any effect on proportion of mothers who continued breastfeeding at 3, 4 and 6 months. There is low-certainty evidence that pharmacological galactagogues may increase milk volume. There is some evidence from subgroup analyses that natural galactagogues may benefit infant weight and milk volume in mothers with healthy, term infants, but due to substantial heterogeneity of the studies, imprecision of measurements and incomplete reporting, we are very uncertain about the magnitude of the effect. We are also uncertain if one galactagogue performs better than another. With limited data on adverse effects, we are uncertain if there are any concerning adverse effects with any particular galactagogue; those reported were minor complaints. High-quality RCTs on the efficacy and safety of galactagogues are urgently needed. A set of core outcomes to standardise infant weight and milk volume measurement is also needed, as well as a strong basis for the dose and dosage form used.

What Evidence Do We Have for Pharmaceutical Galactagogues in the Treatment of Lactation Insufficiency?-A Narrative Review

Inadequate breast milk supply is a frequently reported reason for early discontinuation of breastfeeding and represents a critical opportunity for intervening to improve breastfeeding outcomes. For women who continue to experience insufficient milk supply despite the utilisation of non-pharmacological lactation support strategies, pharmacological intervention with medications used to augment lactation, commonly referred to as galactagogues, is common. Galactagogues exert their pharmacological effects through altering the complex hormonal milieu regulating lactation, particularly prolactin and oxytocin. This narrative review provides an appraisal of the existing evidence regarding the efficacy and safety of pharmaceutical treatments for lactation insufficiency to guide their use in clinical practice. The greatest body of evidence surrounds the use of domperidone, with studies demonstrating moderate short-term improvements in breast milk supply. Evidence regarding the efficacy and safety of metoclopramide is less robust, but given that it shares the same mechanism of action as domperidone it may represent a potential treatment alternative where domperidone is unsuitable. Data on remaining interventions such as oxytocin, prolactin and metformin is too limited to support their use in clinical practice. The review provides an overview of key evidence gaps and areas of future research, including the impacts of pharmaceutical galactagogues on breast milk composition and understanding factors contributing to individual treatment response to pharmaceutical galactagogues.

ABM Clinical Protocol #9: Use of Galactogogues in Initiating or Augmenting Maternal Milk Production, Second Revision 2018

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Use of Psychotropic Medications in Breastfeeding Women

BACKGROUND

Breastfeeding women who are prescribed with psychotropic medications on a regular basis are often concerned, regarding the possible implications of such treatment on the breastfed infant. A mother's well-being has a direct influence on the well-being of the baby. However, the notorious reputation of psychotropic medications may lead to suboptimal prescribing by the physician and poor adherence by the mother.

METHODS

A PubMed search (from 1976 through February 2017) was conducted for commonly used psychotropic drug classes, as well as individual medications commonly prescribed in these classes, along with the MeSH terms "breastfeeding"/"lactation". In each case, we chose studies that describe the pharmacokinetics of passage into breast milk and/or adverse effects in breastfed infants.

RESULTS

No large-scale controlled studies regarding the safety of psychotropic medications in breastfeeding mothers were reported. Based on case reports and small studies, most psychotropic medications produce low milk levels and low plasma levels in the infant, while serious adverse effects in the breastfed infant are rarely reported. Safety data for some psychotropic medications are still unavailable.

CONCLUSION

According to the data available in the literature to date, most psychotropic medications are expected to produce low levels in breast milk with no clinical importance. Nevertheless, an individual risk-benefit assessment of a proposed treatment should always be performed, as inter-individual differences may have a substantial effect on the breastfeeding infant's response to the treatment. Further studies and additional objective data are needed to consolidate and improve our current knowledge of psychopharmacotherapy in breastfeeding women. Birth Defects Research 109:957-997, 2017. © 2017 Wiley Periodicals, Inc.

Pregnancy outcomes in women reporting ingestion of levosulpiride in early pregnancy

This study aimed to evaluate pregnancy outcomes of women who were inadvertently exposed to levosulpiride in early pregnancy. All 162 consecutive singleton pregnant women counselled through the Korean Motherisk Program, Cheil General Hospital, between April 2001 and April 2014, on teratogenic risk after inadvertent exposure to levosulpiride in early pregnancy were enrolled in this study. The women were exposed to levosulpiride at median 4.8 gestational weeks. The rate of miscarriage was not significantly different between groups (9.2% in those exposed and 5.5% in the non-exposed; p = .084). The rate of major malformations was not significantly different between exposed (2.7%) and non-exposed pregnancies (4.4%) (p = .481). All other pregnancy outcomes between the two groups were comparable (p > .05). Our data suggest that levosulpiride causes no significant adverse effects on pregnancy outcomes and therefore may be not a major teratogen.

Pharmacological overview of galactogogues

Galactogogues are substances used to induce, maintain, and increase milk production, both in human clinical conditions (like noninfectious agalactias and hypogalactias) and in massification of production in the animal dairy industry. This paper aims to report the state of the art on the possible mechanisms of action, effectiveness, and side effects of galactogogues, including potential uses in veterinary and human medicine. The knowledge gaps in veterinary clinical practice use of galactogogues, especially in the standardization of the lactogenic dose in some pure drugs and herbal preparations, are reviewed.

ABM Clinical Protocol #9: Use of galactogogues in initiating or augmenting the rate of maternal milk secretion (First Revision January 2011)

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. These guidelines are not intended to be all-inclusive, but to provide a basic framework for physician education regarding breastfeeding.

Collaborative work on evaluation of ovarian toxicity. 17) Two- or four-week repeated-dose studies and fertility study of sulpiride in female rats

To find the appropriate dosing period to detect ovarian toxicity, sulpiride, a D2 antagonist was orally dosed to female rats at dose levels of 1, 10, and 100 mg/kg/day daily for 2 or 4 weeks in repeated-dose toxicity studies. In addition, sulpiride at the same dose levels was given to female rats daily during the pre-mating period, mating period, and Days 0-7 of gestation to assess its effect on fertility. In ovarian histology in the 2-week study, increases in atretic follicle were seen at 1 mg/kg or more and increases in follicular cysts at 10 mg/kg or more. In the 4-week study, these findings were seen at 1 mg/kg or more, and a decrease in large follicles was seen at 10 mg/kg or more. Increased body weight gain was observed at 10 mg/kg or more in the 2- and 4-week studies. The females in these groups exhibited development of mammary alveolus by sulpiride-induced hyperprolactinemia. In the fertility study, sulpiride-treated females showing persistent diestrus resulted in successful mating, and almost all females got pregnant. However, increased implantation loss was observed at 10 mg/kg or more, which was considered to be caused by the adverse effect of sulpiride on oocyte development. From these results, sulpiride-induced ovarian toxicity was seen at 1 mg/kg or more in the 2- and 4-week repeated-dose toxicity studies, and the observed ovarian changes were considered to be related to adverse effects on female fertility.

A critical review of pharmaceutical galactagogues

Use of plant and drug products to enhance lactation is widespread, and numerous papers have been published in the medical literature claiming efficacy for various products. This paper will review and evaluate the published literature on the most widely used pharmaceuticals that are used as galactagogues. Breastfeeding physiology is reviewed with the aim of creating a framework for understanding galactagogue pharmacology. Published articles were selected and evaluated using the principles of evidence-based medicine, and were also evaluated using the principles of good lactation management. Only three studies on oxytocin and seven studies on dopamine antagonists were found to be useful. Oxytocin is probably not useful as a galactagogue, except possibly in rare circumstances of tetraplegic mothers. Dopamine antagonists appear not to enhance milk supply if mothers are given good lactation support and employ these practices. The safety of the dopamine antagonists has not been adequately evaluated, so their use should be avoided unless other measures have failed.

Serum prolactin in breastfeeding: state of the science

Prolactin is one of two major hormones involved in lactation. While the role of infant suckling and oxytocin in the lactation process are well understood, the role of prolactin is less clear. A variety of factors related to prolactin have been investigated, and these are used as an organizing framework for this article. Factors include pregnancy, lactation, nursing frequency, prior lactation experience, milk production, and pharmacologic agents. The literature, while substantial in amount, presents inconsistencies. Implications for practice are discussed.

Drug therapy in the nursing mother

The benefits of breast-feeding on newborn and infant health and for the maternal-infant relationship are well established. It is a failing of health care providers that breast-feeding is too frequently interrupted because of unfounded concerns over the potential adverse effects of concurrent drug therapy in the nursing mother. An overwhelming minority of medications are contraindicated during lactation, while the vast majority are considered either safe to use or the risk versus benefit considerations clearly favor use with continuation of breast-feeding. For those drugs that may pose a potential concern to the newborn, there are practical suggestions and precautions that can be taken to minimize risk. These include such interventions as selection of alternative effective drug regimens with safer profiles in breast-feeding, timing of drug dosing to minimize accumulation in the breast milk, surveillance for newborn or infant symptomatology that may be a sign of toxicity, or even the determination of drug levels in the infant's circulation. With a commitment to the advantages of breast-feeding and the information contained both herein and elsewhere regarding the interaction of medical therapy, pharmacology, and lactation, it is hoped that the health care provider will be empowered both to encourage and counsel more effectively the parturient who wishes to breast-feed but is concerned about ongoing drug therapy during lactation.

A guide to the safety of CNS-active agents during breastfeeding

For most agents with CNS activity, there are limited data regarding their safety in breastfeeding. Any decision to institute treatment for a neurological or psychiatric disorder must weigh the benefits of maternal treatment against the potential harm to the breastfeeding mother of withholding medication which may improve her illness. For the neonate, one must balance the risk of medication exposure against the benefit of receiving breast milk. Most tricyclic antidepressants can be used in lactating women. Because of the limited data, selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors should only be used with due consideration of the potential adverse effects. Breastfeeding is best avoided by women who require lithium therapy, because of both the immature excretory systems in the infant and relatively high doses received by the infant. There is little information about the safety of antipsychotic medications in breastfeeding. Concerns include toxicity and abnormal neurological development in the infant. These agents may be used with caution. Most agents which cause depression of the CNS, including opiates and sedatives, can be used in small doses and for short courses in breastfeeding mothers. Most anticonvulsants can be used in lactating women. Reference texts and consultation with experts are useful adjuncts to discussion of the risks and benefits of therapy with the patient. The scope of this review is limited to drugs with therapeutic uses, thus drugs of abuse are not discussed, nor are caffeine and alcohol (ethanol).

Physiological mechanisms underlying lactational amenorrhea

Breastfeeding delays the resumption of normal ovarian cycles by disrupting the pattern of pulsatile release of GnRH from the hypothalamus and hence LH from the pituitary. The plasma concentrations of FSH during lactation are sufficient to induce follicle growth, but the inadequate pulsatile LH signal results in a reduced estradiol production by these follicles. When follicle growth and estradiol secretion does increase to normal, the suckling stimulus prevents the generation of a normal preovulatory LH surge and follicles either fail to rupture, or become atretic or cystic. Only when the suckling stimulus declines sufficiently to allow generation of a normal preovulatory LH surge to occur will ovulation take place with the formation of a corpus luteum of variable normality. Thus suckling delays the resumption of normal ovarian cyclicity by disrupting but not totally inhibiting, the normal pattern of release of GnRH by the hypothalamus. The mechanism of suckling-induced disruption of GnRH release remains unknown. It does not appear to involve prolactin, dopamine or opiates although a combination of these factors might be involved. Prolactin is the major hormone responsible for milk production and is present in sufficient quantities in almost all women to allow the establishment of normal lactation. Oxytocin is essential for milk let down and is susceptible to inhibition of release by stress. The successful initiation of lactation which would lead to the potential of utilizing breastfeeding as contraceptive may require more attention to be paid to the establishment of non-stress release of oxytocin.

The effect of ergometrine on breast feeding

A randomised, controlled trial of 1429 women was carried out to compare 'active' management of the third stage of labour, using i.v. Ergometrine 0.5 mgs, with a method of 'physiological' management, in women at 'low risk' to haemorrhage. A separate sub-study, with 168 women in each of the two groups, examined the possible effects of Ergometrine on serum prolactin levels and the duration of breast feeding. No difference was found in peak (post-suckling) serum prolactin levels taken from 126 women between 48 and 72 hours postnatal. Further studies with larger sample sizes would give a more dependable result. Women who did not receive the drug Ergometrine were more likely to continue breast feeding for longer than four weeks than those who did (p less than 0.05). It is recommended that this drug should not be given routinely to women intending to breast feed.

Physiology of lactation

The development of the human breast is dependent on the presence of ovarian steroids. The basic secretory units--the alveoli--continue to respond to steroids throughout the reproductive years. Lactogenesis is triggered by a rapid and drastic fall in progesterone at delivery and maintained by prolactin while the actual expulsion of milk from the breast depends on oxytocin. The composition of milk is very variable but is adequate to provide the sole source of nutrients for up to the first 6 months of life. Lactation suppresses ovarian activity probably through a disturbance in the pulsatile pattern of LH secretion but the degree of suppression depends on infant feeding patterns and perhaps on maternal nutritional status. Breastfeeding therefore confers a degree of protection against pregnancy but some artificial methods of contraception are appropriate for use during lactation. It is still not clear whether breastfeeding protects significantly against breast cancer.

Relationships between nursing patterns, supplementary food intake and breast-milk intake in a rural Thai population

Relationships between nursing patterns, supplementary food intake and breast-milk intake were examined in a group of 52 Thai babies under 1 year of age. All data were collected over two consecutive days, 24 h/day. Total sucking time (min/day) and supplementary food intake (kcal/day) were significant predictors of breast-milk intake after allowing for the age of the baby: R-squared is 0.32 for sucking time and 0.39 for supplementary food intake. The two variables were themselves correlated (r is -0.47). The number of breastfeeds per day and their mean duration was determined for each case, counting each episode of attachment to the breast as a separate feed. Number and mean duration of breastfeeds were then evaluated as predictor variables. The duration of feeds had no predictive power. Number of feeds was linearly related to milk intake and combined with age was as good a predictor of milk intake as total sucking time (with R-squared 0.34). These results suggest that a simple count of breastfeeds is as valuable as more complex measures of sucking duration in predicting to breast-milk intake.

Prolactin response to low dose sulpiride

1 Prolactin levels in response to sulpiride were studied in healthy volunteers. 2 Oral doses of 1 mg-50 mg sulpiride or placebo were given. 3 A 3 mg sulpiride dose produced similar levels to those achieved with both 10 mg and 50 mg. 4 Circadian effects were studied showing no significant differences in the prolactin response to sulpiride. 5 Acute or chronic responses showed an attenuation with chronic sulpiride treatment to 50% of the peak levels attained with acute treatment. 6 These results indicate that sulpiride retains its potent ability to produce prolactin release even at the low doses studied here.

Domperidone in defective and insufficient lactation

The clinical use of anti-dopaminergic drugs to stimulate plasma PRL levels, to induce lactogenesis and maintain an adequate lactation has been widely suggested, taking into consideration the main inhibitory role of hypothalamic dopamine on PRL secretion. We therefore studied the effects of domperidone (DOM), a direct anti-dopaminergic drug with a low tendency to be secreted in the milk and which does not cross the blood-brain barrier, on inducing lactogenesis in 8 puerperal women with a history of defective lactogenesis (group A) and inducing galactopoiesis in 9 puerperal women who showed 2 weeks after delivery an insufficient lactation (group B). A placebo treatment was performed in 7 and 8 puerperal women with the same characteristics of group A and B, respectively. PRL plasma levels were assayed in basal conditions and after suckling from the 2nd to the 5th day of puerperium in group A and through a 10-day treatment in group B. In both groups domperidone-treated subjects always showed baseline PRL levels and daily milk yield significantly higher than those of the placebo group (P less than 0.01). The lack of any side-effects and the positive results suggest a high usefulness of such a drug in inducing and/or maintaining successful breast feeding, which is at present considered so important for a healthy development of infants.

Metoclopramide as a lactogogue

Thirty-two mothers with no or inadequate breast milk were treated with metoclopramide. Improved lactation occurred in 66.67 percent of mothers with no breast milk and 100 percent of those with inadequate milk output. Improvement persisted after discontinuing the treatment. No untoward effects were noticed in any of the mothers or their infants.

Domperidone: secretion in breast milk and effect on puerperal prolactin levels

The possible effect on the infant of dopamine antagonists used to promote lactation is cause for concern. Domperidone (Motilium) may be safer than other drugs in this group as it does not cross the blood-brain barrier. The mean serum level of prolactin 2 h after treatment with 20 mg of domperidone in the puerperium was 255 ng/ml compared with 150 ng/ml after a placebo. The mean domperidone level in all breast milk samples during treatment with 10 mg, three times daily, was 2.6 ng/ml. This was significantly more than levels after a single 20 mg dose sampled at 2 h (0.24 ng/ml) and at 4 h (1.1 ng/ml), and considerably less than values available for metoclopramide and sulpiride, relative to the therapeutic dosage. The effectiveness of domperidone to augment lactation requires further study.

Metoclopramide and breast feeding: efficacy and anterior pituitary responses of the mother and the child

The purpose of this randomized, double-blind clinical study was to evaluate the efficacy of the antidopaminergic agent metoclopramide (MC) in the treatment of puerperal lactational insufficiency, and prolactin, TSH and free thyroxine responses of the mother and the child to this therapy. Therefore, 11 women received MC (10 mg 3 times daily orally) and 14 a placebo for 3 wk. MC increased the serum concentration of PRL from 57.5 + 45.5 U/l to 315.0 + 300.0 U/l (P less than 0.001), and the amount of daily milk yield in 8 women with established lactational deficiency rose from 285 + 75 ml to 530 + 162 ml (P less than 0.01) while the placebo was ineffective. Serum concentrations of TSH and free thyroxine did not change during either of the treatments. Serum concentrations of PRL, TSH and free thyroxine in the infants were similar in both groups and remained unchanged throughout the study. Our results suggest that MC is useful in the treatment of deficient puerperal lactation, and it does not stimulate the pituitary lactotropes or thyrotropes of the nursing infants.

The prolactin response to suckling

Changes in prolactin concentration during single suckling episodes in twenty breast-feeding women from four to 40 weeks post partum have been investigated. Basal prolactin concentration and the increase in prolactin secretion in response to single suckling episodes and amount of milk taken by the infant were both independent of time post partum until the introduction of supplementary feeds, when a significant decrease with time was apparent. Basal concentrations of prolactin were dependent upon the interval between suckling episodes, and the magnitude of the prolactin response varied with the time of day when suckling took place. The relationship between acute suckling episodes and the long term pattern of prolactin secretion over time post partum is discussed.

Metoclopramide and breast milk

Thirteen primiparous nursing mothers participated in this placebo-controlled double blind trial of metoclopramide. Therapy was started on the first postpartum day and continued for 8 days. Seven women received metoclopramide (10 mg, 3 X dd). Serum prolactin and milk yield were measured during the trial. The breast milk composition was analysed during the trial and weekly for 3 wk after the trial. A detailed analysis of the amino acid content was performed on the 6th and 21st postpartum days. During the early puerperium the total milk yield was ca. 50% greater in the metoclopramide-treated group compared to the control group. The evolution of the breast milk composition was similar for both groups, except for the amino acid content. The shift in amino acid composition occurred earlier in the treatment group indicating that metoclopramide enhances the rate of transition from colostrum to mature milk.

Metoclopramide and breast feeding: transfer into milk and the newborn

The pharmacokinetics and endocrinological effects of metoclopramide were investigated in 5 mothers with deficient lactation and in their children soon after delivery. In addition, the transfer of metoclopramide into breast milk was evaluated in 18 mothers during the 8th to 12th puerperal weeks. Metoclopramide was detected in all the milk samples studied, generally at a higher concentration than in maternal plasma. Metoclopramide was found in plasma from only 1 of the 5 neonates studied. Exposure of the child to metoclopramide, estimated by multiplying the daily breast milk volume by the concentration of metoclopramide in the milk, ranged from 6 to 24 micrograms/kg/day for the 5 children in the early puerperium to 1 to 13 micrograms/kg/day for the 18 children during the late puerperium. These quantities are considerably less than the therapeutic dose of 500 micrograms/kg/day recommended for children. However, the plasma concentration of prolactin in 4 out of 7 neonates sampled taken during administration of metoclopramide to the mother were higher than the highest plasma prolactin level in children of same age of untreated mothers. The plasma concentration of thyrotrophin in the newborns remained within the normal range.