How to manage low breastmilk production due to low prolactin levels?

Management of Low Breastmilk Production Due to Low Prolactin Levels

Galactogogues such as metoclopramide or domperidone are the recommended pharmacological interventions for managing low breastmilk production due to low prolactin levels, with domperidone being preferred due to fewer central nervous system side effects.

Understanding Prolactin's Role in Lactation

Prolactin is the principal lactogenic hormone critical for establishing lactation, milk production, and maintaining milk secretion 1. It is secreted by the anterior pituitary gland and functions to:

• Stabilize and promote transcription of casein mRNA
• Stimulate synthesis of alpha-lactalbumin (regulatory protein of lactose synthetase)
• Increase lipoprotein lipase activity in mammary tissue 2

During normal pregnancy, prolactin levels increase 10-20 times over normal amounts, but milk production is inhibited by high progesterone levels until after delivery 2. After birth, suckling stimulates prolactin release, which maintains milk production.

Causes of Low Prolactin Levels

Several factors can contribute to low prolactin levels and subsequent insufficient milk production:

• Maternal obesity (BMI >26 kg/m²) has been shown to diminish prolactin response to suckling in the first week postpartum 3
• Inadequate breast stimulation or infrequent feeding
• Certain medications that affect dopamine pathways
• Underlying hormonal imbalances

Assessment of Low Milk Production

Before initiating treatment:

1. Confirm low prolactin levels through laboratory testing
2. Assess feeding technique and frequency
3. Rule out other causes of insufficient milk supply (e.g., poor latch, ineffective milk removal)
4. Evaluate maternal risk factors including obesity, which negatively affects prolactin response to suckling 3

Management Options

Non-pharmacological Approaches (First-line)

• Increase frequency of breastfeeding or pumping (8-12 times per day)
• Ensure proper latch and positioning
• Use breast compression during feeding
• Consider "switch nursing" (alternating breasts multiple times during one feeding)
• Address any maternal obesity, as higher BMI is associated with lower prolactin response to suckling 3

Pharmacological Approaches (Second-line)

When non-pharmacological approaches are insufficient, galactogogues may be considered:

1. Domperidone (preferred option):

   • Mechanism: Dopamine antagonist that increases prolactin secretion
   • Dosage: Typically 10-20 mg three to four times daily
   • Advantages: Does not cross blood-brain barrier readily, resulting in fewer central nervous system side effects 4
   • Note: FDA approval status varies by country

2. Metoclopramide:

   • Mechanism: Dopamine antagonist that increases prolactin secretion
   • Dosage: Usually 10 mg three times daily for 7-14 days
   • Caution: Associated with central nervous system side effects including depression
   • Important: Metoclopramide is excreted in human milk, so caution should be exercised when administered to nursing mothers 5

Important Considerations and Precautions

• Duration of treatment: Generally limited to 2-4 weeks for metoclopramide due to risk of tardive dyskinesia with prolonged use
• Monitoring: Regular assessment of milk production and infant weight gain
• Side effects:
  • Metoclopramide: Risk of depression, anxiety, and extrapyramidal symptoms 5
  • Domperidone: Potential cardiac arrhythmias at high doses in at-risk patients

Special Considerations

• Breastfeeding can be maintained even with normal levels of prolactin (around 500 μU/L) with an average milk production of approximately 260g per day 6
• Prolactin appears to play a permissive role in established lactation rather than being directly proportional to milk volume 6
• Milk production can be maintained with declining prolactin levels during extended lactation 6

When to Consider Alternative Feeding Methods

If despite optimal management milk production remains insufficient:

• Consider supplementation with donor milk if available
• Formula supplementation may be necessary to ensure adequate infant nutrition
• Maintain whatever breastfeeding is possible, as partial breastfeeding still provides benefits

Remember that adequate milk production can occur even with relatively normal prolactin levels in established lactation 6, suggesting that improving the initial prolactin response is most critical in the early postpartum period.