What medication can increase milk production in lactating women?

Medications to Increase Milk Production in Lactating Women

Domperidone is the preferred medication to increase milk production in lactating women due to its efficacy and favorable safety profile compared to alternatives like metoclopramide. 1

First-Line Pharmacological Option: Domperidone

Mechanism and Efficacy

• Acts as a dopamine receptor antagonist, increasing prolactin levels which enhances milk production 1
• Significantly increases breast milk production in mothers with insufficient lactation 2
• In a 2021 randomized controlled trial, domperidone increased breast milk production from 156 mL to 400.9 mL after 14 days of treatment 2
• A systematic review showed domperidone demonstrated a significant increase in daily milk volume (90.53 mL/day) in mothers of preterm infants 3

Dosage and Administration

• Recommended dosage: 10 mg three times daily for 10-14 days 1
• Some studies have used 20 mg three times daily with clinically better (though not statistically significant) results 4
• Earlier initiation (within first 21 days postpartum) leads to better outcomes 5

Safety Profile

• Very low transfer to breast milk (0.01-0.35% relative infant dose) 1
• High plasma protein binding (93%) 1
• No significant adverse effects reported in clinical trials 2, 3
• Significantly improves exclusive breastfeeding rates at hospital discharge (95% vs 52.4% with placebo) 2

Second-Line Option: Metoclopramide

Mechanism and Efficacy

• Also acts as a dopamine receptor antagonist to increase prolactin secretion 1
• Less effective than domperidone based on systematic review data 3
• Meta-analysis showed no significant difference in milk volume compared to placebo in mothers of preterm infants 3

Dosage and Administration

• Recommended dosage: 10 mg three times daily for 10-14 days 1

Safety Considerations

• Higher relative infant dose (4.7-14.3%) compared to domperidone (0.01-0.35%) 1
• Higher incidence of maternal side effects including fatigue, nausea, headache, and dry mouth 1
• FDA warning about potential for extrapyramidal symptoms 6
• Can be used as a galactagogue but may increase milk supply with more side effects than domperidone 6

Clinical Decision Algorithm

1. First confirm non-pharmacological approaches have been optimized:

   • Ensure proper latch and positioning
   • Frequent breastfeeding (8-12 times per 24 hours)
   • Complete breast emptying
   • Adequate maternal hydration and nutrition

2. If milk production remains inadequate:

   • First choice: Domperidone 10 mg three times daily for 14 days
   • Monitor milk production during treatment
   • Consider extending treatment if beneficial but inadequate response
   • Consider higher dose (20 mg three times daily) if initial response is poor

3. If domperidone is unavailable or contraindicated:

   • Metoclopramide 10 mg three times daily for 10-14 days
   • Monitor closely for side effects including extrapyramidal symptoms
   • Discontinue if significant side effects occur

Important Considerations and Pitfalls

• Domperidone is not FDA-approved in the US for any indication but is widely used internationally as a galactagogue
• Avoid using clonidine as it may reduce prolactin secretion and potentially decrease milk production 7
• Both domperidone and metoclopramide should be gradually tapered rather than abruptly discontinued to prevent sudden drop in milk supply
• Pharmacological interventions should be used as adjuncts to, not replacements for, proper lactation support and counseling
• In one study, 71.7% of mothers increased milk production with proper lactation counseling alone, without medications 2