What is the recommended treatment for milk suppression in postnatal care (PNC)?

Milk Suppression in Postnatal Care

Cabergoline is the recommended first-line pharmacological treatment for milk suppression in postnatal care due to its superior efficacy, safety profile, and convenient single-dose administration.

Pharmacological Options for Milk Suppression

First-Line Treatment

• Cabergoline
  • Dosing: 1 mg oral single dose within 24 hours after delivery, or divided as 0.25 mg twice daily for 2 days 1, 2
  • Efficacy: 78-100% success rate in preventing lactation 2, 3
  • Advantages:
    • Single dose administration
    • Lower rate of rebound breast symptoms compared to bromocriptine
    • Better tolerated than other dopamine agonists 4
    • Long-acting (effects last up to 21 days) 4

Alternative Option

• Pyridoxine (Vitamin B6)
  • Dosing: 200 mg three times daily for 7 days
  • Efficacy: Lower than cabergoline (35% vs 78% success rate) 3
  • Advantages: Fewer adverse effects (9% vs 31% with cabergoline)
  • Consider when: Cabergoline is contraindicated (hypertensive disorders, fibrotic, cardiac, or hepatic diseases) 3

Non-Pharmacological Methods

• Breast binding/compression: May provide symptomatic relief
• Cold compresses: Can reduce engorgement and pain
• Avoidance of breast stimulation: Prevents milk production stimulation
• Limited expression of milk: Only for comfort, not to stimulate production

Special Considerations

Contraindications for Cabergoline

• Hypertensive disorders
• Fibrotic diseases
• Cardiac diseases
• Hepatic diseases 3

Diuretics and Milk Suppression

• Diuretics (furosemide, hydrochlorothiazide, spironolactone) may reduce milk production 5
• However, they are generally not preferred in breastfeeding women due to potential effects on electrolyte balance

Monitoring and Follow-up

• Assess for breast engorgement, pain, and milk leakage on days 2,7, and 14 after treatment
• Monitor for adverse effects:
  • Common side effects of cabergoline: dizziness, headache, nausea (usually self-limited) 1
  • Watch for signs of mastitis (fever, breast tenderness, redness)

Treatment Algorithm

1. Assess contraindications for cabergoline (hypertension, cardiac, hepatic, or fibrotic diseases)
2. If no contraindications: Administer cabergoline 1 mg as a single dose within 24 hours after delivery
3. If contraindicated: Use pyridoxine 200 mg three times daily for 7 days
4. For all patients: Implement non-pharmacological measures (breast binding, cold compresses)
5. Monitor for treatment success and adverse effects
6. If treatment failure occurs with pyridoxine, consider switching to cabergoline if contraindications have resolved

Common Pitfalls to Avoid

• Delaying treatment beyond 24-48 hours after delivery reduces efficacy
• Using bromocriptine, which has more adverse effects and requires a longer treatment course
• Incomplete counseling about potential side effects
• Failing to provide non-pharmacological support measures
• Not monitoring for signs of mastitis, which may require additional treatment

Cabergoline has demonstrated superior efficacy to other options, with the most recent evidence from 2024 confirming its superiority over pyridoxine (78% vs 35% success rate) 3. The convenience of single-dose administration and lower rate of rebound symptoms make it the preferred pharmacological option for milk suppression in postnatal care.