What medications, including galactagogues and psychiatric medications such as Selective Serotonin Reuptake Inhibitors (SSRIs), can facilitate milk secretion and support lactation?

Medications to Facilitate Milk Secretion

Domperidone and metoclopramide are the primary pharmaceutical galactagogues that facilitate milk secretion, with domperidone being preferred due to lower central nervous system penetration and reduced risk of maternal and infant side effects. 1

Primary Pharmaceutical Galactagogues

Domperidone (First-Line Agent)

• Domperidone is used as a galactagogue and may increase milk supply, with low levels in milk due to first-pass hepatic and intestinal metabolism when taken orally. 1
• All blinded, placebo-controlled trials of domperidone showed significant increases in milk production compared to placebo. 2
• Domperidone effectively increased milk volume in 7 of 10 Japanese mothers with insufficient lactation, with prolactin levels increasing in 9 of 10 mothers. 3
• Domperidone crosses the blood-brain barrier and enters breast milk to a lesser extent than metoclopramide, decreasing toxicity risk to both mother and infant. 4
• Ensure the woman has access to a breast pump if there is any delay in feeding her infant when using domperidone. 1

Critical Caveat: Domperidone may pose significant psychiatric withdrawal risks upon discontinuation, including symptoms lasting months that are clinically distinct from postpartum depression. 5 A slow hyperbolic taper should be used to minimize withdrawal manifestations. 5

Metoclopramide (Alternative Agent)

• Metoclopramide is also used as a galactagogue and may increase milk supply. 1
• Metoclopramide remains a galactagogue option due to its documented record of efficacy and safety in women and infants. 4
• However, only 1 of 6 clinical trials showed significant differences in milk production compared to placebo, making it less consistently effective than domperidone. 2
• Metoclopramide has greater central nervous system penetration than domperidone, potentially increasing side effect risk. 4

Mechanism of Action

• Most galactagogues exert their pharmacologic effects through interactions with dopamine receptors, resulting in increased prolactin levels and thereby augmenting milk supply. 4

Role of Psychiatric Medications (SSRIs)

Fluoxetine (Prozac) and Breastfeeding

• Fluoxetine is excreted in human milk, and nursing while on Prozac is not recommended according to FDA labeling. 6
• In one breast milk sample, the concentration of fluoxetine plus norfluoxetine was 70.4 ng/mL, with maternal plasma concentration of 295.0 ng/mL. 6
• One case reported an infant nursed by a mother on fluoxetine who developed crying, sleep disturbance, vomiting, and watery stools, with infant plasma drug levels of 340 ng/mL fluoxetine and 208 ng/mL norfluoxetine. 6
• SSRIs do not function as galactagogues and are not used to facilitate milk secretion. Their role in lactation is limited to treating maternal psychiatric conditions, not enhancing milk production.

Herbal Galactagogues

• Clinical trials on herbal galactagogues including shatavari, fenugreek, silymarin, garlic, and malunggay showed mixed results. 2
• Fenugreek has been purported to be effective in anecdotal reports, though use should be considered after evaluating risks versus benefits. 4

Medications That May DECREASE Milk Production (Avoid)

• Clonidine may reduce prolactin secretion and therefore could reduce milk production in the early postpartum period. 1, 7
• Atropine may inhibit lactation and is found in trace concentrations in breast milk with potential antimuscarinic effects in the infant. 1, 7

Clinical Algorithm for Galactagogue Use

1. First, ensure non-pharmacological interventions have been attempted: adequate breast stimulation, frequent feeding/pumping, proper latch, maternal hydration and nutrition.

2. If pharmacological intervention is needed, choose domperidone as first-line: 10 mg three times daily. 3

3. Monitor for efficacy: Assess milk volume increase within 4-7 days of initiation. 3

4. Screen for cardiac contraindications: Obtain baseline electrocardiogram before starting domperidone due to rare risk of QT prolongation and cardiac events. 3

5. Plan for discontinuation from the start: Use a slow hyperbolic taper over weeks to months to minimize psychiatric withdrawal symptoms. 5

6. Consider metoclopramide as second-line if domperidone is contraindicated or unavailable, though evidence for efficacy is less robust. 2