What is the comparative efficacy of domperidone (Domperidone) versus metoclopramide (Metoclopramide) for inducing lactation?

From the Guidelines

Domperidone is the preferred choice over metoclopramide for increasing lactation due to its better safety profile and fewer central nervous system side effects. When considering the use of these medications, it is essential to weigh the benefits of increased lactation against potential risks and side effects. According to the guideline on anaesthesia and sedation in breastfeeding women 2020 from the Association of Anaesthetists 1, both metoclopramide and domperidone may be used as galactagogues to increase milk supply. However, domperidone is noted to have low levels in milk due to first-pass hepatic and intestinal metabolism, making it a safer option.

Key points to consider when prescribing domperidone for lactation include:

• Typical dosing: 10-20 mg three to four times daily
• Mechanism of action: blocking dopamine receptors to increase prolactin levels and enhance milk production
• Side effects: dry mouth, headache, and gastrointestinal disturbances
• Monitoring: treatment duration should be limited to 3-4 weeks with careful monitoring
• Tapering: the medication should be tapered rather than abruptly discontinued to minimize potential side effects

In contrast, metoclopramide carries additional risks, including tardive dyskinesia with prolonged use. While metoclopramide may be used in lactating women, its potential for central nervous system side effects makes domperidone a more attractive option for increasing lactation. As with any medication, non-pharmacological approaches like frequent breastfeeding, proper latching techniques, and adequate hydration should be optimized before considering medication 1.

From the Research

Comparison of Domperidone and Metoclopramide for Increased Lactation

• Domperidone has been shown to increase milk production in lactating mothers, particularly those with preterm infants 2, 3.
• Metoclopramide, on the other hand, did not demonstrate a significant increase in daily human milk volume in women with preterm infants 2, 3.
• The efficacy of domperidone in increasing milk production is attributed to its ability to inhibit dopamine-2 receptors, leading to an increase in prolactin levels 4, 5.
• However, domperidone is associated with serious cardiac arrhythmias, including QT prolongation, torsades de pointes, and sudden cardiac death 6, 4.
• Metoclopramide is also a prokinetic agent, but its use for lactation enhancement is not well established, and it may not be as effective as domperidone in increasing milk production 2, 3.
• Both domperidone and metoclopramide have been reported to have similar maternal side effects, with no significant differences noted in women with preterm infants 2, 3.

Safety Considerations

• The use of domperidone for lactation enhancement is not approved in any country, and its importation is illegal in the United States, with limited exceptions 6.
• The U.S. Food and Drug Administration (FDA) has issued a public safety warning regarding the use of domperidone for lactation due to its potential cardiac risks 6.
• Despite the safety concerns, domperidone is still being used off-label for lactation enhancement in some countries, highlighting the need for further research and caution 4, 5.

Efficacy in Preterm and Term Infants

• Domperidone has been shown to be effective in increasing milk production in mothers of preterm infants 2, 3.
• However, its efficacy in term infants is less clear, with some studies suggesting no significant benefit compared to metoclopramide or placebo 3.
• Metoclopramide did not demonstrate a significant increase in daily human milk volume in women with preterm or term infants 2, 3.