Effect of domperidone on the composition of preterm human breast milk

Oral domperidone versus placebo for enhancing exclusive breastfeeding among post-lower segment cesarean section mothers - a double-blind randomized controlled trial

OBJECTIVE

To assess whether oral domperidone compared to placebo increases the rate of exclusive breastfeeding for 6 months among post-lower segment cesarean section (LSCS) mothers.

METHODS

This double-blind Randomized Controlled Trial, conducted in a tertiary care teaching hospital in South India, included 366 post-LSCS mothers with delayed initiation of breastfeeding or with subjective feelings of not having enough milk. They were randomized to two groups - Group A: Standard lactation counseling and oral Domperidone and Group B: Standard lactation counseling and a placebo. The primary outcome was an exclusive breastfeeding rate at 6 months. Exclusive breastfeeding rates at 7 days and 3 months and serial weight gain of an infant were assessed in both groups.

RESULTS

Exclusive breastfeeding rate at 7 days was statistically significant in the intervention arm. The exclusive breastfeeding rates at 3 months and 6 months were higher in the domperidone arm compared to placebo but not statistically significant.

CONCLUSION

Oral Domperidone along with effective breastfeeding counseling showed an increasing trend of exclusive breastfeeding rate at 7 days and at six months. Appropriate breastfeeding counseling and postnatal lactation support are important in enhancing exclusive breastfeeding.

TRIAL REGISTRATION

The study was prospectively registered with CTRI - Reg no. CTRI/2020/06/026237.

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.

Psychiatric Manifestations of Withdrawal Following Domperidone Used as a Galactagogue

Background: Domperidone is a dopamine-2 antagonist used off-label to increase breast milk production. Dosages commonly promoted for lactation are often far above those of studied on-label indications and might pose additional risks, especially upon discontinuation of the drug. Patients: Three U.S. patients are presented who used domperidone for lactation and experienced varying degrees of psychiatric withdrawal symptoms lasting months during dosage tapering and after cessation. Conclusion: Domperidone as a galactagogue may pose a significant psychiatric risk upon discontinuation. This presentation is commonly confused with, but clinically distinct from, postpartum depression. Lactating mothers who present with psychiatric symptoms should be explicitly probed about domperidone use, even in areas where domperidone is not authorized for use. Maternal hesitancy to disclose domperidone use may lead to suboptimal outcomes for the patient and delay management of withdrawal manifestations. The best course of treatment remains unknown, but a slow hyperbolic taper to gently discontinue domperidone may minimize withdrawal symptoms in these patients. Individuals exploring domperidone use should be informed of potential risks upon withdrawal, including psychiatric manifestations, requisite taper, and potential impacts of using unstudied high doses.

Efficacy of Wang Nam Yen herbal tea on human milk production: A randomized controlled trial

Background

Insufficient milk production is a common problem affecting breastfeeding women, in particular following Cesarean delivery. Wang Nam Yen herbal tea is a promising traditional Thai medicine used by postpartum women to stimulate milk production, as an alternative to pharmaceutical galactagogues. We aimed to compare the efficacy of Wang Nam Yen herbal tea, domperidone, and placebo, in increasing milk production in mothers who underwent Cesarean delivery.

Methods

Women who underwent uncomplicated cesarean delivery at Sunpasitthiprasong Hospital were randomized into three groups. The participants received the treatments daily for three consecutive days. The primary outcome was breast milk volume at 72 hours after delivery. Secondary outcomes were pregnancy and neonatal outcomes, adverse events, and participant satisfaction.

Results

Of the 1,450 pregnant women that underwent cesarean delivery, 120 women were enrolled. Their mean age and gestational ages were 28.7 years and 38.4 weeks, respectively. Breast milk volume at 72 hours postpartum was significantly different among the three groups (p = 0.030). The post hoc Bonferroni correction indicated a significant difference in breast milk volume between Wang Nam Yen herbal tea group and placebo control group (p = 0.007) while there was no difference between Wang Nam Yen herbal tea group and domperidone group (p = 0.806) and between domperidone group and placebo control group (p = 0.018). There was no difference in pregnancy and neonatal outcomes, adverse events, and participant satisfaction among the three groups.

Conclusion

Wang Nam Yen herbal tea was effective in augmenting breast milk production at 72 hours postpartum in mothers following cesarean delivery, and there was no evidence that herbal tea and domperidone differed in terms of augmenting breast milk production.

Trial registration

The study was approved by the institutional review board of Sunpasitthiprasong Hospital (No.061/2559) and was registered TCTR20170811003 with the Thai Clinical Trial Registry.

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.

Off-label postpartum use of domperidone in Canada: a multidatabase cohort study

BACKGROUND

Trends in off-label postpartum use of domperidone and the impact of safety advisories on its use remain unknown. Our objectives were to describe postpartum use of domperidone in Canada, to evaluate the impact of Health Canada advisories on prescribing patterns, and to describe the association between domperidone use and a composite end point of sudden cardiac death or ventricular tachycardia (VT) among postpartum patients.

METHODS

We conducted a multidatabase cohort study involving pregnant patients with live births between 2004 and 2017 using administrative health databases from 5 Canadian provinces (British Columbia, Alberta, Saskatchewan, Manitoba and Ontario). We excluded patients with less than 1 year of prepregnancy database history and with approved indications for domperidone. We assessed domperidone use in the 6 months postpartum and the impact of the 2012 and 2015 Health Canada advisories on prescribing via interrupted time series analysis. We estimated crude rates of VT and sudden cardiac death.

RESULTS

We included 1 190 987 live births. Mean maternal age was 28.6 (standard error 0.6) years. Domperidone use increased over time, from 7% in 2003-2005 to 12% in 2009-2011, when it plateaued. The 2012 advisory was followed by a drop in use and a reduction in slope, and the 2015 advisory had a more modest impact. Crude analysis suggests that domperidone may be associated with increased VT or sudden cardiac death (0.74 v. 0.37 per 10 000 person-years; difference per 10 000 person-years: 0.37, 95% confidence interval -0.67 to 1.41).

INTERPRETATION

Postpartum domperidone use increased between 2004 and 2017, with prescribing attenuated after Health Canada advisories and a very low absolute rate of VT or sudden cardiac death. These findings suggest that Health Canada advisories affected prescribing; any potential increase in VT or sudden cardiac death with use of domperidone is small and could not be confirmed in this large study STUDY REGISTRATION: ClinicalTrials.gov, no. NCT04024865.

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

Objective: Mothers of many preterm babies are unable to produce sufficient milk for their babies during the prolonged hospitalization. Domperidone stimulates the release of prolactin, thereby increasing breast milk production. The primary outcome was to study the efficacy of domperidone in augmenting breast milk production in mothers with lactation failure (LF). The secondary outcomes included the effect of domperidone on prolactin levels, adverse effects of domperidone, and outcome on breastfeeding rates at discharge. Materials and Methods: This was a randomized, double-blinded, placebo-controlled trial where mothers with LF were either allocated domperidone (10 mg) or placebo, 2 tablets three times a day for 14 days. Milk volumes were recorded daily for 14 days. Serum prolactin levels were measured at the start and at day 7 of study. Results: Out of 166 women eligible for the study, 119 (71.7%) mothers were able to increase their breast milk production without pharmacological treatment after being counseled on the advantages of human milk and proper breastfeeding management. Forty-seven mothers were finally enrolled in the study; 24 in the domperidone group (DG) and 23 in the placebo group (PG). Breast milk production increased from a baseline of 156 + 141.1 to 400.9 + 239.2 mL in the DG and increased from a baseline of 175.8 + 150.7 to 260.5 + 237.5 mL in the PG, after 14 days (p < 0.01). The prolactin levels in the DG and PG increased from 72.85 (22.2-167.15) and 42.33 (14.02-93.54) ng/mL, respectively, to 223.4 (49.79-280.2) ng/mL (p = 0.005) in the DG and 60.08 (14.31-132.14) ng/mL (p = 0.232) in the PG on the 7th day of treatment. No adverse effects were recorded. Ninety-five percent of babies in the DG were exclusively breastfeeding at hospital discharge, compared with 52.4% in the PG (p = 0.008). Conclusion: Domperidone treatment can result in an increase in breast milk production with no adverse effects. The study was registered with the Thai Clinical Trials Registry ID TCTR2020091008.

Effect of Low-Level Laser Therapy versus Electroacupuncture on Postnatal Scanty Milk Secretion: A Randomized Controlled Trial

OBJECTIVE

Postnatal scanty milk secretion is a common complaint. Some physical and medical interventions were advocated to help milk production. These interventions should be effective and safe for the mother and the infant. This study aimed to compare the effects of low-level laser therapy and electroacupuncture on postnatal scanty milk secretion.

STUDY DESIGN

A randomized controlled study conducted on 60 healthy primiparous mothers with insufficient lactation. They were randomly divided into three equal groups: group A (control), group B (those who received low-power He-Ne laser beam on both breasts), and group C (those who received faradic current stimulation at Spleen 6, Liver 3, and Small Intestine 1 acupuncture points on both sides). All participants received 10 mg Domperidone three times a day and were given advice about lactation, nutrition, and fluid intake. Evaluation was done before and after the treatment program.

RESULTS

The mean serum prolactin, infant weight, and visual analog scale (VAS) score were significantly increased in the three groups posttreatment when compared with their corresponding levels pretreatment. Posttreatment serum prolactin was significantly elevated in group C more than the other two groups (p = 0.001 and 0.012, respectively). Also, it was significantly elevated in group B more than in group A (p = 0.001). The mean value of infant weight was significantly elevated in group C when compared with its corresponding values in both groups A (p = 0.001) and B (p = 0.029). The VAS score was significantly increased in both groups B and C when compared with group A (p = 0.001).

CONCLUSION

Electroacupuncture is more effective than low-level laser therapy in increasing postnatal scanty milk secretion.

CLINICAL TRIAL REGISTRATION

NCT03806062.

Effects of Domperidone in Increasing Milk Production in Mothers with Insufficient Lactation for Infants in the Neonatal Intensive Care Unit

Breast milk is the optimum for all infants, but hospitalization in the neonatal intensive care unit can cause separation of mothers and infants, which often interferes with milk secretion. Some reports show that domperidone is effective in promoting milk secretion. However, the Food and Drug Administration in the United States cautioned to not use domperidone for increasing milk volume because domperidone carries some risk of cardiac events, including QT prolongation, cardiac arrest, and sudden death. In contrast, it is used in Canada, Australia, and the United Kingdom with safety. The pharmacodynamics and pharmacokinetics of drugs may vary by race or ethnic origin, and it is not known whether domperidone is effective or safe for Japanese. In this study we report the effects of domperidone for Japanese mothers with insufficient lactation. Ten mothers were enrolled in a pilot study. After confirming that there were no abnormal findings on the electrocardiogram, the mothers were administered domperidone. Seven of 10 who took domperidone increased their milking volume. Prolactin was increased in 9 of 10 mothers. Adverse events were observed in two mothers, one headache and one abdominal pain; all symptoms were mild and improved promptly; and there were no adverse cardiac events. These results are consistent with reports from other countries. Domperidone may tentatively be considered effective for increasing milk secretion in Japanese mothers as in other populations. Our preliminary study of 10 cases indicates the need for further studies with larger sample sizes to assess the efficacy and safety of domperidone.

Milk-derived miRNA profiles elucidate molecular pathways that underlie breast dysfunction in women with common genetic variants in SLC30A2

Studies in humans and pre-clinical animal models show milk-derived miRNAs reflect mammary gland function during lactation. The zinc transporter SLC30A2/ZnT2 plays a critical role in mammary gland function; ZnT2-null mice have profound defects in mammary epithelial cell (MEC) polarity and secretion, resulting in sub-optimal lactation. Non-synonymous genetic variation in SLC30A2 is common in humans, and several common ZnT2 variants are associated with changes in milk components that suggest breast dysfunction in women. To identify novel mechanisms through which dysfunction might occur, milk-derived miRNA profiles were characterized in women harboring three common genetic variants in SLC30A2 (D¹⁰³E, T²⁸⁸S, and Exon 7). Expression of ten miRNAs differed between genotypes, and contributed to distinct spatial separation. Studies in breast milk and cultured MECs confirmed expression of ZnT2 variants alters abundance of protein levels of several predicted mRNA targets critical for breast function (PRLR, VAMP7, and SOX4). Moreover, bioinformatic analysis identified two novel gene networks that may underlie normal MEC function. Thus, we propose that genetic variation in genes critical for normal breast function such as SLC30A2 has important implications for lactation performance in women, and that milk-derived miRNAs can be used to identify novel mechanisms and for diagnostic potential.

Human Milk Expression After Domperidone Treatment in Postpartum Women: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Insufficient milk production is among the most cited reasons by mothers for discontinuing breastfeeding. Medications that can increase milk production, such as domperidone, an off-label galactagogue, are often prescribed. Domperidone is controversial as it is not approved for any purpose in the United States and is approved only for gastrokinetic purposes in Canada and other countries.

RESEARCH AIM

The aim was to update the existing literature on the efficacy of domperidone as a galactagogue compared to placebo when given to mothers with insufficient human milk production. The primary outcome is the change in expressed human milk volume per day from baseline.

METHODS

The authors independently searched the literature from inception to May 2018. The search included any randomized controlled trials examining the efficacy of domperidone increasing mothers' expressed human milk, measured via a human milk pump. Both authors independently assessed quality and risk of bias and extracted relevant data. Meta-analysis on expressed human milk volume per day was performed.

RESULTS

Seven studies met the inclusion criteria for review; two were excluded from the meta-analysis due to quality grading and insufficient reporting of the outcome of interest. Five studies (N = 239) were combined in the meta-analysis. The effect size showed an increase in the mean difference of expressed human milk volume in mothers given domperidone, 93.97 mL per day (95% CI [71.12, 116.83 mL]; random effect, T² 0.00, I² 0%).

CONCLUSION

This meta-analysis reports a significant improvement in expressed human milk volume per day with the use of domperidone in mothers experiencing insufficient human milk production.

Role of days postdelivery on breast milk production: a secondary analysis from the EMPOWER trial

Background

With an increasing demand for mother's own milk to be viewed as a primary source of nutritional support in the care of very small and preterm infants, mothers of preterm infants may be at risk of expressing suboptimal amounts of milk. The use of a galactogogue is often considered when these mothers are still having challenges in breast milk production.

Methods

For this analysis, the study participants were the 90 mothers who participated in the EMPOWER trial and, at the time of randomization, were stratified by days post-delivery, 8-14 days and 15-21 days. The primary outcome measure was the proportion of mothers in each of the days post-delivery groups who achieved a 50% increase in breast milk volume on day 14 of the study treatment period.

Results

There was no significant difference in the proportion of mothers in the 8-14 days group (75.0%) who achieved a 50% increase in breast milk volume on day 14 of the study treatment period.compared to those in the 15-21 days group (60.9%), OR 1.93 (95% CI 0.78, 4.76; p = 0.15). Because comorbidities and exposure to antenatal corticosteroids between the groups of mothers were viewed as potential confounders, a logistic regression was performed after controlling for these two variables with the adjusted OR being 1.84 (0.73, 4.64; p = 0.19).

Conclusions

This secondary analysis was able to demonstrate that mothers of very preterm infants, < 30 weeks gestation at birth, were able to respond to the study treatment in a similar fashion regardless of timing of entry and exposure to domperidone. In the presence of a suboptimal breast milk production by the end of the first week postpartum, below 250 ml/kg/d based on infant birth weight, a 14 day treatment of domperidone could be considered to augment breast milk production.

Trial registration

EMPOWER has been registered at http://www.clinicaltrials.gov (identifier NCT01512225) on January 10, 2012.

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.

Evaluating the Effect of a 14-Day Course of Domperidone on Breast Milk Production: A Per-Protocol Analysis from the EMPOWER Trial

BACKGROUND

Galactogogues are often considered when mothers of very preterm infants experience challenges in producing adequate amounts of breast milk. We conducted a per-protocol analysis of those mothers who completed a 14-day course of domperidone during the EMPOWER trial. Our primary aim was to evaluate the response to a completed course of domperidone and whether the response was affected by the timing of the initiation of intervention.

METHODS

For this analysis, 83 mothers of infants ≤29 weeks gestation were included: 45 mothers who received domperidone from days 1 to 14 of the trial study treatment period and 38 mothers who received domperidone from days 15 to 28. Domperidone was given at a dose of 10 mg thrice daily for 14 days. The primary outcome was the proportion of mothers who achieved a modest 50% increase in breast milk volume from the volume at the end of the 2-week period of treatment of domperidone.

RESULTS

When adjusted for the initiation of domperidone treatment, the proportion of mothers in the days 1-14 group (77.8%) was similar compared to those in the days 15-28 group (65.8%), OR 1.96 (95% CI 0.72-5.32; p = 0.19).

CONCLUSION

Taking into consideration potential limitations in power, this secondary analysis was able to show that the mothers in the EMPOWER study who were identified as actually completing a 14-day treatment course responded irrespective of the timing of their initiation of domperidone and demonstrated a modest increase in breast milk volume.

Pregnancy gestation at delivery and breast milk production: a secondary analysis from the EMPOWER trial

Background

Preterm birth alters the normal sequence of lactogenesis. Lactogenesis I may not yet have started when mothers of very preterm infants (≤ 29 weeks gestation) have given birth. Preterm infants are too small or too ill to initiate suckling in the immediate postpartum period thus altering the normal cascade of event for lactogenesis II. With an increasing demand for mother’s own milk as a primary source of nutritional support in the care of very small and preterm infants, mothers of these infants are often at risk of expressing inadequate amounts of milk. The use of galactogogues is often considered when mothers of preterm infants are still having challenges in breast milk production. What is not clear in the literature is the role that pregnancy gestation at birth plays in successful response to galactogogues. Our objective for this study was to evaluate the role of pregnancy gestation at birth on a mother’s response to the treatment interventions in the EMPOWER trial.

Methods

For this analysis, the study participants are the 90 mothers who participated in the EMPOWER trial and were in the stratified in two gestational age groups, 23^0/7–26^6/7 weeks and 27^0/7–29^6/7 weeks at the time of randomization. The primary outcome measures were the proportion of mothers in each of the gestational age groupings who achieved a 50% increase in breast milk volume on day 14 and day 28 of the study treatment period.

Results

On day 14 of the study treatment, there was no significant difference in the proportion of mothers in the 23–26 weeks gestation group (72.9%) compared to those in the 27–29 weeks gestation group (64.2%), OR 1.51 (95% CI 0.60, 3.78; p = 0.38). Similarly, there was no difference in the proportion of mothers between the two gestational age groupings on day 28 of the study treatment, 70.3% compared to 62.3%, OR 1.43 (95% CI 0.58, 3.51; p = 0.43).

Conclusion

This secondary analysis was able to demonstrate that mothers of very preterm infants, < 30 weeks gestation at birth, were able to respond to the study treatment in a similar fashion regardless of gestation at birth. If non-pharmacologic approaches are unsuccessful, then a 14–day treatment of domperidone may be considered to enhance breast milk production, even in the lowest gestational ages at delivery.

Trial registration

EMPOWER has been registered at www.clinicaltrials.gov (identifier NCT 01512225) on January 10, 2012.

Domperidone for insufficient lactation in England 2002-2015: A drug utilization study with interrupted time series analysis

PURPOSE

Our aim was to describe trends in the prescription of domperidone for insufficient lactation in England, the characteristics of women prescribed it postpartum, and the impact of a 2014 European Medicines Agency (EMA) recommendation to restrict its use due to a potential increased risk of sudden cardiac death associated with its use.

METHODS

We conducted a population-based cohort study with interrupted time series analysis using data from the Clinical Practice Research Datalink linked to Hospital Episode Statistics. We identified women with live births from 2002 to 2015, excluding those with nonlactation indications for domperidone (n = 247 349). We evaluated trends in the prescription rate of domperidone in the 6 months postpartum and differences in this rate before and after the EMA recommendation.

RESULTS

Domperidone was prescribed among 1438 deliveries at a rate of 1.24 per 100 person-years. This rate increased from 0.56 to 2.1 per 100 person-years between 2002-2004 and 2011-2013 (rate ratio: 3.8; 95% confidence interval [CI], 3.2-4.6). Prescribing decreased in level by 0.35 (95% CI, -0.86 to 0.16) per 100 person-years immediately following the recommendation with little change in trend (0.003; 95% CI, -0.059 to 0.065 per 100 person-years). Following the recommendation, prescription of doses >30 mg and coprescription of drugs with a risk of torsade de pointes decreased. No arrhythmic events were observed among domperidone users.

CONCLUSIONS

Although we observed an important increase in prescribing during the study period, domperidone remains infrequently prescribed postpartum in England. While overall prescribing changed little, some prescribing practices became more restricted following the EMA's recommendation.

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.

Supporting Mothers of Very Preterm Infants and Breast Milk Production: A Review of the Role of Galactogogues

Human milk, either mother’s own milk or donor human milk, is recommended as the primary source of nutrition for very preterm infants. Initiatives should be in place in neonatal units to provide support to the mother as she strives to initiate and maintain a supply of breast milk for her infant. The use of galactogogues are considered when these initiatives alone may not be successful in supporting mothers in this endeavor. Although there are non-pharmacologic compounds, this review will focus on the pharmacologic galactogogues currently available and the literature related to their use in mothers of very preterm infants.

Longer-term breastfeeding outcomes associated with domperidone use for lactation differs according to maternal weight

PURPOSE

To examine differences in longer-term breastfeeding outcomes among mothers of preterm infants according to domperidone exposure status, as well as examine the potential for effect modification according to maternal weight.

METHODS

Retrospective cohort study of 198 mothers of very preterm infants (born ≤ 30 weeks' gestation) who initiated breastfeeding and whose infants survived until hospital discharge. Data on domperidone use were obtained from hospital pharmacy records, with the primary outcome defined as continuation of breastfeeding at infant discharge from the Neonatal Unit. The relationship between domperidone exposure and breastfeeding status was investigated using multivariable regression analysis, adjusting for potential confounders. Additional pre-determined analyses were undertaken following stratification according to maternal weight to investigate the presence of effect modification.

RESULTS

No overall difference was observed in the proportion of mothers continuing to breastfeed at the time of infant discharge from the Neonatal Unit according to whether or not they received domperidone (aRR 0.99; 0.86-1.13). Notably, effect modification was observed according to maternal weight, with use of domperidone associated with a reduced likelihood of breastfeeding at discharge among women ≥ 70 kg (aRR 0.72; 0.54-0.97), but not among those < 70 kg (aRR 1.16; 0.92-1.46).

CONCLUSIONS

Despite experiencing low milk supply, longer-term breastfeeding outcomes were similar between women who did and did not use domperidone. Differences in domperidone effectiveness according to maternal weight have important implications for clinical practice given the increasing prevalence of overweight/obesity in reproductive-age women and their higher risk of low milk supply, highlighting the importance of further research in this area.

Domperidone Versus Metoclopramide: Self-Reported Side Effects in a Large Sample of Breastfeeding Mothers Who Used These Medications to Increase Milk Production

Introduction: Metoclopramide and domperidone are medications that block dopamine receptors on the lactotrophs, allowing prolactin levels to rise. Both medications are prescribed to boost milk production in mothers with low milk production due to hypoprolactinemia. The Food and Drug Administration has not approved the use of domperidone in the U.S. because of concerns about increased risk of cardiac arrhythmias. Metoclopramide is often recommended instead. Unfortunately, metoclopramide affects the central nervous system (CNS) and increases the risk of both depression and tardive dyskinesia (TD).

Method: The present study is an online survey of self-reported side effects of 1,990 mothers, representing 25 countries, who took metoclopramide, domperidone, or both medications to enhance milk production. Data were collected in 2010.

Results: The results indicated that side effects, in general, affected only a small percentage of women who took either medication. Women were 3.6 times more likely to report no side effects when taking domperidone vs. metoclopramide. There were no significant differences in cardiac arrhythmias for women who took metoclopramide versus domperidone. Racing heart was more common with metoclopramide. Less than 1% reported these symptoms in both groups. However, CNS effects were significantly more common in women who took metoclopramide. Risk of depression increased by seven times, and symptoms of TD (tremors, involuntary grimaces, and jerking) increased by 4 to 19 times when women took metoclopramide.

Discussion: The results of the present study are preliminary, but suggest that cardiac arrhythmias are a rare side effect with both medications. The CNS side effects with metoclopramide are more concerning, particularly depression and TD. It is hoped that the recommendations regarding the relative safety of these medications will be re-examined in light of these findings.

Should Domperidone be Used as a Galactagogue? Possible Safety Implications for Mother and Child

Domperidone has been used as a galactagogue; however, solid evidence from an adequate sized randomized clinical trial is missing. Optimal dosage, start of treatment, length of treatment and scope of patients who can benefit also remain unknown. Although milk obtained after domperidone administration has not been shown to have untoward effects on newborns, no sufficiently large randomized clinical trial has been done to establish safety. Domperidone has repeatedly been shown to produce sudden cardiac death, starting at 30 mg/day. Because of this known cardiac effect, the use of domperidone to increase breast milk production may not be justified.

Enhancing Human Milk Production With Domperidone in Mothers of Preterm Infants

BACKGROUND

Mothers of preterm infants often are at risk of expressing an inadequate amount of milk for their infants and the use of galactogogues is often considered. Domperidone is a widely used galactogogue with little information available to guide clinicians regarding initiation, timing, and duration of treatment. Research aim: The primary objective of this study was to determine whether administration of domperidone within the first 21 days after delivery would lead to a higher proportion of mothers achieving a 50% increase in the volume of milk at the end of 14 days of treatment compared with mothers receiving placebo.

METHODS

Eligible mothers were randomized to one of two treatment arms: Group A-domperidone 10 mg orally three times daily for 28 days; or Group B-placebo 10 mg orally three times daily for 14 days followed by domperidone 10 mg orally three times daily for 14 days.

RESULTS

A total of 90 mothers of infants ≤ 29 weeks gestation were randomized. Mean milk volumes at entry were similar for both groups. More mothers achieved a 50% increase in milk volume after 14 days in Group A (77.8%) compared with Group B (57.8%), odds ratio = 2.56, 95% confidence interval [1.02, 6.25], p = .04.

CONCLUSION

A greater number of mothers experienced a 50% or more increase in human milk volume, but the absolute increase in milk volume was modest.

Health provider experiences with galactagogues to support breastfeeding: a cross-sectional survey

BACKGROUND

Exclusive breastfeeding for infants up to 6 months is widely recommended, yet breastfeeding rates are relatively low in the US. The most common reason women stop breastfeeding early is a perceived insufficiency of milk. Galactagogues are herbal and pharmaceutical products that can help increase milk supply; however, data on their efficacy and safety is limited. Lactation consultants, obstetricians, and other health providers are an important point of contact for breastfeeding women experiencing challenges with lactation. This study explored providers' perceptions, experiences, and practices in relation to galactagogue recommendation.

METHOD

A cross-sectional survey was conducted among a convenience sample of English-speaking health providers in the US who counsel breastfeeding women and their infants.

RESULTS

More than 70% of respondents reported to recommend galactagogues. The most frequently recommended galactagogue was fenugreek with respondents indicating that they recommend it either 'always' (8.5%) or 'most of the time' (14.9%) and 'sometimes' (46.8%). More than 80% of the respondents indicated that galactagogues were useful for their clients and only one-third reported side effects. Reasons for refraining from recommending galactagogues were insufficient evidence of its efficacy and safety. Respondents reported a wide variety of sources of information used for their own education about galactagogues.

DISCUSSION

Despite little evidence regarding safety and efficacy, some galactagogues are widely recommended and often perceived to be useful. However, concerns about their efficacy and safety remain. In order to assure both providers and users about safety and efficacy, more robust studies as well as better pharmacovigilance systems are needed.

Feasibility and Acceptability of Two Complementary and Alternative Therapies for Perceived Insufficient Milk in Mothers of Late Preterm and Early Term Infants

Background: Complementary and alternative medicine (CAM) could be one option to address perceived insufficient milk (PIM), but there are few data comparing the effectiveness, acceptability, and safety of various CAM therapies. The purpose of this study was to describe and compare, among women delivering at 34-376/7 weeks, the feasibility and acceptability of two CAM interventions for treatment of PIM: (1) a meditation/relaxation intervention via an MP3 (Apple iPod Shuffle©) player and (2) a commercially available combination-blend herbal supplement (Motherlove: More Milk Plus Alcohol Free®). Materials and Methods: After randomization, over 9 days, women received three home visits from a lactation consultant, recorded pre/post intervention test weights and expressed milk volume, tracked daily breastfeeding behavior, and completed an end-of-study interview about the interventions. Women in each group were offered the other group's intervention on study day 9. Breastfeeding status and intervention continuation were assessed at 2 months. Results: Of 183 women screened, 11 were eligible, enrolled into, and completed the 9-day trial. Six women were randomized to the herbal supplement and 5 to meditation. One participant (meditation) stopped breastfeeding on study day 8. At 2 months, 3 of 6 women assigned to the herbal supplement and 3 of 5 women assigned to meditation were still breastfeeding; 1 (herbal supplement) was exclusively breastfeeding. Most participants were adherent to the prescribed protocols for both interventions. Interventions were generally perceived as safe, with benefits not necessarily related to increased milk supply. Conclusion: Mothers of late preterm and early term infants who had PIM found the CAM interventions acceptable and safe. The effect of CAM therapies on breastfeeding outcomes, with and without in-home lactation assistance, requires further investigation.

Domperidone for Treatment of Low Milk Supply in Breast Pump-Dependent Mothers of Hospitalized Premature Infants: A Clinical Protocol

Mothers of hospitalized premature infants who choose to provide breast milk are at increased risk of an inadequate breast milk supply. When nonpharmacologic interventions to increase milk supply fail, clinicians are faced with limited options. There is no current evidence to support the use of herbal galactogogues in this population and a black box warning for metoclopramide for potential serious side effects. Thus, domperidone was the only known, effective option for treatment of low milk supply in this population. With a thorough review of the literature on domperidone and coordination with the obstetrical, neonatal, lactation, and pharmacology teams, a domperidone treatment protocol for mothers of hospitalized premature infants with insufficient milk supply was developed at our institution and is presented in this article. A comprehensive understanding of domperidone for use as a galactogogue with a standard treatment protocol will facilitate safer prescribing practices and minimize potential adverse reactions in mothers and their hospitalized premature infants.

Postpartum domperidone use in British Columbia: a retrospective cohort study

BACKGROUND

Domperidone is commonly used off-label to stimulate milk production in mothers who have low milk supply. The aim of this study was to describe trends, patterns and determinants of postpartum domperidone use.

METHODS

This is a retrospective, population-based study involving all women with a live birth between Jan. 1, 2002, and Dec. 31, 2011, in the province of British Columbia. We examined administrative data sets containing person-specific information on filled prescriptions and use of medical services, and we used logistic regression to examine associations between domperidone use and maternal characteristics.

RESULTS

The study population consisted of 225 532 women with 320 351 live births. The prevalence of postpartum domperidone use more than doubled between 2002 and 2011. In 2011, 1 in 3 women with a preterm birth and 1 in 5 women with a full-term birth were prescribed domperidone in the first 6 months postpartum. Women who were older, had a higher body mass index, had a chronic disease, were first-time mothers, delivered more than 1 baby (multiple pregnancy), had a preterm birth or had a cesarian delivery were more likely to fill a postpartum domperidone prescription.

INTERPRETATION

We found an increase in postpartum domperidone use over a 10-year period. More research is needed on maternal and infant health outcomes.

Euprolactinemic galactorrhea secondary to domperidone treatment

Milk leakage from the breast, which is known as galactorrhea, can be caused by a number of pharmacological, physical, and tumoral factors. Galactorrhea is a well-known side effect of domperidone, and is usually associated with hyperprolactinemia. However, euprolactinemic galactorrhea secondary to domperidone is very rarely seen and has yet to be reported in children before. Here, we report an adolescent with euprolactinemic galactorrhea caused by domperidone.

Factors associated with domperidone use as a galactogogue at an Australian tertiary teaching hospital

BACKGROUND

Insufficient milk supply is 1 of the most commonly reported reasons for discontinuation of infant breastfeeding. Although domperidone is often used to improve milk supply, knowledge of factors associated with the use of domperidone in clinical practice is scarce.

OBJECTIVE

This study aimed to examine factors associated with the use of domperidone as a galactogogue at the Women's and Children's Hospital (WCH), Adelaide.

METHODS

A retrospective cohort study was conducted, involving women who delivered live-born singletons (N = 21 914) at the WCH between January 2004 and December 2008. Women dispensed domperidone were identified using WCH pharmacy dispensing records. Maternal and infant clinical data were obtained from the WCH Perinatal Statistics Collection. Relationships between maternal/infant demographic and clinical variables and the use of domperidone were examined through univariate and multivariate logistic regression analyses.

RESULTS

Key factors associated with an increased likelihood of women receiving domperidone were increasing maternal age (adjusted odds ratio [aOR] = 1.04; 95% confidence interval [CI], 1.03-1.06), maternal obesity (aOR = 1.41; 95% CI, 1.16-1.77), primiparity (aOR = 1.94; 95% CI, 1.63-2.30), delivery by cesarean section (aOR = 1.31; 95% CI, 1.10-1.55), preterm birth (aOR = 3.54; 95% CI, 2.79-4.50), and neonatal hospitalization (aOR = 2.51; 95% CI, 2.01-3.14). In addition, statistically significant trends were observed between increasing socioeconomic status and year of delivery and an increased likelihood of women receiving domperidone (all Ps < .004).

CONCLUSION

These findings are of clinical importance as they not only reinforce previous findings regarding risk factors for women experiencing lactation difficulties but also highlight the need for improved research regarding the rational and efficacious use of domperidone to improve breastfeeding outcomes.

Use of domperidone as a galactagogue drug: a systematic review of the benefit-risk ratio

Breastfeeding is the optimal method for feeding a newborn. However, some mothers may have difficulties lactating. Domperidone is widely used as a galactagogue but to the best of our knowledge has not been approved by any health authority. The objective of this review was to assess the benefit-risk ratio of domperidone for stimulating lactation. The benefit-risk ratio of domperidone as a galactagogue was assessed following a literature search of the PubMed database up to July 2013. Four studies were selected to assess domperidone efficacy and demonstrated an increased milk production. The limited data (60 mother-baby pairs) and the moderate methodological quality of 1 study remain insufficient to conclude on domperidone efficacy. Regarding the safety of domperidone, 7 studies were selected that exposed 113 infants to domperidone through breastfeeding. No adverse effects were observed in 85 infants, and no information was provided for the remaining 28. The limited data available remain in favor of a safe domperidone profile in infants and mothers. However, in large studies focused on gastrointestinal disorders, domperidone is responsible for drug-induced long QT syndrome and sudden cardiac death. The use of domperidone as a galactagogue is worrisome as drug-induced long QT syndrome occurred mostly in women. In these circumstances, an improvement of breastfeeding practices seems to be more effective and safer than the use of an off-label domperidone treatment.

An Intervention to Promote Breast Milk Production in Mothers of Preterm Infants

A pilot study was conducted to estimate the effects of a breast milk expression education and support intervention on breast milk production outcomes in mothers of very and extremely preterm infants. Forty mothers of hospitalized preterm infants (<30 weeks of gestation) were randomized to the experimental intervention or standard care for 6 weeks. Duration and frequency of breast milk expressions and volume of expressed breast milk were measured daily. Samples of breast milk were collected thrice during the study and analyzed for their lipid concentration. Mothers in the experimental group had a statistically significant higher duration of breast milk expression in min/day ( p = .043). Differences observed between the two groups regarding the frequency of breast milk expression, volume of breast milk, and lipid concentration were not statistically significant. Results suggest that the experimental intervention may promote breast milk production in mothers of very and extremely preterm infants.

Effect of mode of delivery on macronutrient content of breast milk

OBJECTIVE

To determine the effect of delivery type on macronutrient content of colostral milk.

MATERIALS AND METHODS

The study was conducted at Zekai Tahir Burak Maternity Teaching Hospital. Colostral milk samples from term lactating mothers who gave birth by vaginal or cesarean delivery (CD) were obtained on the 2nd postpartum day. Milk protein, fat, carbohydrate (CHO) and energy levels were measured by using a mid-infrared human milk analyzer.

RESULTS

A total of 204 term lactating mothers were recruited to the study; 111 mothers gave birth by vaginal route and 93 mothers by CD. Protein levels were statistically lower in colostral milk of mothers after CD compared to mothers who delivered vaginally (median 2.4 (range 0.3-6.4) g/dl versus 3 (0.5-6.3) g/dl, respectively; p = 0.036). Colostral fat, CHO and energy levels were similar between groups. In linear regression analysis, CD and maternal age were independently associated with lower protein content in colostrum.

CONCLUSION

Vaginal delivery is associated with higher colostrum protein content. Hormonal activity induced by labor pain and uterine contractions might account for the alterations in the protein composition of human milk to facilitate optimal development of important physiologic functions in newborns.

The transfer of drugs and therapeutics into human breast milk: an update on selected topics

Many mothers are inappropriately advised to discontinue breastfeeding or avoid taking essential medications because of fears of adverse effects on their infants. This cautious approach may be unnecessary in many cases, because only a small proportion of medications are contraindicated in breastfeeding mothers or associated with adverse effects on their infants. Information to inform physicians about the extent of excretion for a particular drug into human milk is needed but may not be available. Previous statements on this topic from the American Academy of Pediatrics provided physicians with data concerning the known excretion of specific medications into breast milk. More current and comprehensive information is now available on the Internet, as well as an application for mobile devices, at LactMed (http://toxnet.nlm.nih.gov). Therefore, with the exception of radioactive compounds requiring temporary cessation of breastfeeding, the reader will be referred to LactMed to obtain the most current data on an individual medication. This report discusses several topics of interest surrounding lactation, such as the use of psychotropic therapies, drugs to treat substance abuse, narcotics, galactagogues, and herbal products, as well as immunization of breastfeeding women. A discussion regarding the global implications of maternal medications and lactation in the developing world is beyond the scope of this report. The World Health Organization offers several programs and resources that address the importance of breastfeeding (see http://www.who.int/topics/breastfeeding/en/).

The effect of two different domperidone doses on maternal milk production

BACKGROUND

The benefits of breast milk to the newborn infant are well established. The Canadian Paediatric Society recommends exclusive breastfeeding for the first 6 months of life for healthy, term infants. Mothers of premature newborns, however, may have difficulty providing an adequate supply of breast milk. Domperidone is officially used as a prokinetic agent. However, it is used widely around the world as a galactogogue. Despite its widespread use as a galactogogue, only a small number of investigators have studied domperidone for this indication.

AIMS

The purpose of this study was to determine an optimal dosage of domperidone as a galactogogue.

METHODS

Eligible subjects were randomized to receive domperidone 10 mg 3 times daily or domperidone 20 mg 3 times daily for 4 weeks. At week 5, the frequency was decreased to twice daily in both groups, and finally once daily for week 6.

RESULTS

Over the entire first 4-week period, there was a significant increase in daily milk volumes within each group (P < .01). The between-group difference over this period, although not statistically significant, was clinically significant. Additionally, there was no significant within- or between-group difference during weeks 5 and 6.

CONCLUSION

A dose of domperidone of 20 mg, 3 times daily instead of 10 mg, 3 times daily was associated with a clinical, but not statistically significant, increase in milk production.

Audit of domperidone use as a galactogogue at an Australian tertiary teaching hospital

BACKGROUND

Domperidone is often used to promote lactation among women who have difficulty breastfeeding.

OBJECTIVE

To examine prescribing and dispensing practices of domperidone at the Women's and Children's Hospital (WCH), Adelaide.

METHODS

A retrospective audit of domperidone dispensing among women with singleton pregnancies who delivered at the WCH between January 2000 and July 2010 was undertaken. Women dispensed domperidone were identified using WCH pharmacy dispensing records. Maternal and infant clinical data were obtained from the WCH Perinatal Statistics Collection. An audit of paper-based medical records was undertaken for a random sample of 261 mother-child pairs to collect prescribing and additional clinical data.

RESULTS

From 2000 to 2010, 1605 women were dispensed domperidone. There was a steady increase in the percentage of women dispensed domperidone, from < 0.5% in 2000 to > 5% of total WCH pregnancies in 2010. Among women dispensed domperidone, the percentage of women who received > 1 dispensing remained consistent (20%) over time, as did the median number of days (12) from delivery to first dispensing. Multiparous women were more likely to receive domperidone within 3 days following delivery compared to primiparous women (8% vs 4%; P < .01). Most women (80%) received directions to take domperidone according to a standard tapering dosing regimen over 12 days. Notably, 60% of women had no documentation of being assessed by a lactation consultant.

CONCLUSION

From 2000 to 2010, there was a considerable increase in domperidone dispensing. With a lack of clinical evidence to guide use, current practice appears to be based on anecdotal evidence.

The use of galactogogues in the breastfeeding mother

OBJECTIVE

To review data regarding the efficacy of galactogogues available in the US to increase breast milk production in postpartum mothers.

DATA SOURCES

Literature was sought using PubMed (1966-June 2012) and EMBASE (1973-June 2012). Search terms included breastfeeding, breast milk, lactation, galactogogue, metoclopramide, oxytocin, fenugreek, milk thistle, silymarin, growth hormone, thyroid releasing hormone, medroxyprogesterone, domperidone, goat's rue, beer, Asparagus racemosus, shatavari, Medicago sativa, alfalfa, Onicus benedictus, blessed thistle, Galega officinalis, brewer's yeast, and herbals.

STUDY SELECTION AND DATA EXTRACTION

All studies including humans and published in English with data assessing the efficacy of galactogogues for increasing breast milk production were evaluated.

DATA SYNTHESIS

Breast milk is considered the optimal food source for newborns through 1 year of age. Many factors influence overall maternal production, including maternal pain, illness, balance of time when returning to work, anxiety, or emotional stress. Although a variety of herbal and pharmaceutical options have anecdotal evidence of their ability to improve breast milk production, peer-reviewed studies proving their efficacy are lacking. Metoclopramide, oxytocin, fenugreek, and milk thistle have shown mixed results in improving milk production; however, the trials were small and had a variety of limitations.

CONCLUSIONS

Nonpharmacologic recommendations should be exhausted before adding therapy. Although anecdotal evidence encourages the use of metoclopramide, fenugreek, asparagus, and milk thistle for their galactogogue properties, efficacy and safety data in the literature are lacking. Oxytocin and domperidone are potentially available for compounding purposes, but safety data are limited. More studies are needed to evaluate the effects of available galactogogues on breast milk production.

Enhancing breast milk production with Domperidone in mothers of preterm neonates (EMPOWER trial)

Background

The use of mother’s own breast milk during initial hospitalization has a positive impact not only in reducing potential serious neonatal morbidities but also contribute to improvements in neurodevelopmental outcomes. Mothers of very preterm infants struggle to maintain a supply of breast milk during their infants’ prolonged hospitalization. Galactogogues are medications that induce lactation by exerting its effects through oxytocin or prolactin enhancement. Domperidone is a potent dopamine D₂ receptor antagonist which stimulates the release of prolactin. Small trials have established its ability in enhancing breast milk production. EMPOWER was designed to determine the safety and efficacy of domperidone in mothers experiencing an inadequate milk supply.

Methods/design

EMPOWER is a multicenter, double masked, randomized controlled phase-II trial to evaluate the safety and effectiveness of domperidone in those mothers identified as having difficulty in breast milk production. Eligible mothers will be randomized to one of two allocated groups: Group A: domperidone 10 mg orally three times daily for 28 days; and Group B: identical placebo 10 mg orally three times daily for 14 days followed by domperidone 10 mg orally three times daily for 14 days. The primary outcome will be determined at the completion of the first 2-week period; the second 2-week period will facilitate answering the secondary questions regarding timing and duration of treatment. To detect an estimated 30% change between the two groups (from 40% to 28%, corresponding to an odds ratio of 0.6), a total sample size of 488 mothers would be required at 80% power and alpha = 0.05. To account for a 15% dropout, this number is increased to 560 (280 per group). The duration of the trial is expected to be 36–40 months.

Discussion

The use of a galactogogue often becomes the measure of choice for mothers in the presence of insufficient breast milk production, particularly when the other techniques are unsuccessful. EMPOWER is designed to provide valuable information in guiding the practices for this high-risk group of infants and mothers. The results of this trial will also inform both mothers and clinicians about the choices available to increase and maintain sufficient breast milk.

Trial registration

Clinical Trials.gov Identifier: NCT01512225

Medications for increasing milk supply in mothers expressing breastmilk for their preterm hospitalised infants

BACKGROUND

Breastmilk remains the optimal form of enteral nutrition for term and preterm infants until up to six months postnatal age. Mothers of preterm infants who have not established suck feeds must express their breastmilk and often have difficulty in maintaining sufficient volume for their infants' needs (Donath 2008). In preterm infants, donor breastmilk reduced the occurrence of necrotising enterocolitis, when compared with formula feeds (McGuire 2003). Also, case-control studies have suggested that breastmilk is associated with an improvement in feeding tolerance, a reduction in significant gastrointestinal infective events (Beeby 1992) and a reduction in late-onset sepsis (Schanler 1999) when compared with formula feeds in preterm hospitalised infants.

OBJECTIVES

To assess the effect of medication given for at least seven days to mothers of preterm infants whose breastmilk is insufficient for their infants' needs on the outcomes of expressed milk volume and duration of breastfeeding.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2011).

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of breastmilk-augmenting medications (compared with placebo or with other augmenting medications) in mothers with preterm hospitalised infants whose breastmilk volumes failed to meet their infants' requirements. We did not include trials with a cluster-randomised or cross-over design.

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed studies for inclusion, assessed risk of bias, and extracted data. Any differences were resolved by consensus. Data were checked for accuracy.

MAIN RESULTS

Two trials (involving 59 mothers) that examined the use of domperidone in a total of 59 mother-infant pairs met the inclusion criteria. Meta-analysis of these trials showed a modest increase in expressed breastmilk (EBM) of 99.49 mL/day (95% confidence intervals -1.94 to 200.92; random-effects, T² 3511.62, I² 63%) in mothers given domperidone. Both trials gave the same dose of domperidone (10 mg three times per day) with a duration of seven days in the smaller trial and 14 days in the larger.Neither trial showed significant improvements in longer-term outcomes of breastfeeding in a preterm population and no adverse effects were reported.

AUTHORS' CONCLUSIONS

Two studies with a total of 59 mothers suggest modest improvements in short-term EBM volumes when a medication is used after insufficient EBM occurs in mothers following preterm delivery. In both studies, the medication was commenced ≧14 days post delivery and following insufficient EBM supply with other lactation supports.Currently, no studies support prophylactic use of a galactagogue medication at any gestation. Use of any galactagogue medication has only been examined at more than 14 days post delivery and after full lactation support has been given. Further trials should examine larger groups of preterm mothers and consider breastfeeding outcomes over a longer period.

Effect of domperidone on insufficient lactation in puerperal women: a systematic review and meta-analysis of randomized controlled trials

Background. There is a controversy within the medical community regarding the role of domperidone as a galactagogue and the drug has been removed from the US market owing to safety concerns. Objective. To perform a systematic review and meta-analysis of the available data assessing the effect of domperidone on breast milk production in women experiencing insufficient lactation. Study Selection. Randomized controlled trials (RCTs) examining the effect of domperidone on breast milk production of puerperal women were eligible for inclusion. Data Analysis. Absolute and relative changes from baseline were calculated for individual studies and pooled using a random effects model. Results. Three RCTs including 78 participants met the inclusion criteria. All showed a statistically significant increase in breast milk production following treatment with domperidone. The analysis of pooled data demonstrated a statistically significant relative increase of 74.72% (95%  CI = 54.57; 94.86, P < 0.00001) in daily milk production with domperidone treatment compared to placebo. No maternal or neonatal adverse events were observed in any of the trials. Conclusions. Evidence from a few small RCTs of moderate to high quality suggests that domperidone produces a greater increase in breast milk supply than placebo.

Breastfeeding the infant with congenital diaphragmatic hernia post extracorporeal membrane oxygenation

Infants born with congenital diaphragmatic hernia (CDH) often require extracorporeal membrane oxygenation (ECMO). Infants on ECMO may experience a long period of being nothing by mouth (NPO) while receiving parenteral nutrition. Once the infant with CDH is repaired and off ECMO, human milk should be used to initiate enteral feedings. Human milk provides immunologic, developmental, and nutritional protection for these highrisk infants and may be crucial in decreasing morbidities commonly associated with post-ECMO survivors. These mother-infant dyads require extensive lactation support to ensure maintenance of milk supply and successful transition to direct breastfeeding. Three case studies are presented as exemplars to demonstrate how breastfeeding success can be achieved even in the most vulnerable infants.

Effects of domperidone on augmentation of lactation following cesarean delivery at full term

OBJECTIVE

To evaluate the effects of domperidone on breast milk production in women who underwent cesarean at full term.

METHODS

Women who underwent uncomplicated full-term cesarean were randomly assigned to receive domperidone or placebo for 4 consecutive days post partum. Breast milk was collected twice daily via electric breast pump. Baseline milk production was determined by measuring the volume of milk collected on the 1st postpartum day, before initiation of study medication (day 0). The daily volume of milk collected was compared between groups. Adverse treatment-related effects were recorded.

RESULTS

The study was completed by 22 women in the domperidone group and 23 in the placebo group. Compared with day 0, mean increases in milk volume per participant collected on days 1, 2, 3, and 4 were significantly higher in the domperidone (13.6 ± 23.2 mL, 68.5 ± 71.9 mL, 144.5 ± 122.3 mL, and 191.3 ± 136.1 mL) than in the placebo (2.5 ± 4.6 mL, 24.5 ± 26.5 mL, 72.1 ± 55.6 mL, and 91.4 ± 60.3 mL) group. Minor adverse effects were reported by 7 women in the domperidone group.

CONCLUSION

Postpartum treatment with domperidone can augment breast milk production after full-term cesarean, with minimal adverse effects.

The thymic epithelial microRNA network elevates the threshold for infection-associated thymic involution via miR-29a mediated suppression of the IFN-α receptor

Thymic output is a dynamic process, with high activity at birth punctuated by transient periods of involution during infection. Interferon-α (IFN-α) is a critical molecular mediator of pathogen-induced thymic involution, yet despite the importance of thymic involution, relatively little is known about the molecular integrators that establish sensitivity. Here we found that the microRNA network dependent on the endoribonuclease Dicer, and specifically microRNA miR-29a, was critical for diminishing the sensitivity of the thymic epithelium to simulated infection signals, protecting the thymus against inappropriate involution. In the absence of Dicer or the miR-29a cluster in the thymic epithelium, expression of the IFN-α receptor by the thymic epithelium was higher, which allowed suboptimal signals to trigger rapid loss of thymic cellularity.

Breastfeeding self-efficacy and the use of prescription medication: a pilot study

Objective. To examine the association of self-efficacy, perception of milk production, and lactating women's use of medication prescribed to increase breast milk in a cohort of 18–40-year-old mothers over six months. Methods. Mothers (n = 76) attending community clinics completed the Breastfeeding Self-Efficacy Scale and the Humenick/Hill Lactation Scale, a measure of perceived milk production, three times. Results. Domperidone, a dopamine antagonist, was used by 28% of participants. On average, those using domperidone had lower self-efficacy scores than those not using it (P < 0.05) and were more likely to have used formula (Pearson chi-square test statistic  = 6.87, df = 1, P < 0.05). Breastfeeding self efficacy and perception of milk production were positively correlated. Conclusion. Breastfeeding assessment conducted prior to prescription of galactogogues is recommended for mothers and healthy term babies. Following Baby-Friendly hospital protocols and increasing self-efficacy for lactating women may be most effective in sustaining breastfeeding. Risks and benefits of various galactogogues are discussed.

Principles for maintaining or increasing breast milk production

Breastfeeding rates in many developed countries remain low, and maternal perception of insufficient milk production is a major contributing factor. Mothers with a perception of insufficient milk should be advised that normal breastfeeding frequencies, suckling times, and amounts are very variable. If objective assessment confirms insufficient milk production, mothers should ensure optimal milk removal frequency and thorough breast drainage. In addition, galactogogues can be prescribed. Understanding physiological principles underlying milk production will help clinicians reassure and assist mothers.