What is the recommended dose of Reglan (metoclopramide) for increasing milk supply?

Recommended Reglan (Metoclopramide) Dose for Increasing Milk Supply

The recommended dose of metoclopramide (Reglan) for increasing milk supply is 10 mg orally three times daily, though evidence suggests domperidone may be more effective with fewer side effects for this indication. 1, 2

Standard Dosing Protocol

• Metoclopramide 10 mg orally three times daily is the established dose when used as a galactogogue, typically administered 30 minutes before meals and at bedtime 1
• Treatment duration should be limited due to risk of tardive dyskinesia with prolonged use; most studies evaluate 10-14 day courses 3, 4
• The medication can be administered orally or intravenously at the same 10 mg dose if oral route is not feasible 1, 5

Efficacy Evidence

• Metoclopramide is compatible with breastfeeding and may increase milk supply through its galactogogue properties 6
• A 2021 meta-analysis found metoclopramide did not show significant increase in daily milk volume in mothers of preterm infants (mean difference -1.14 mL/day), whereas domperidone demonstrated a significant 90.53 mL/day increase 4
• A 2012 head-to-head trial showed both medications increased milk production (93.7% increase for metoclopramide vs 96.3% for domperidone), but differences were not statistically significant 7
• Metoclopramide remains "the galactogogue of choice due to its documented record of efficacy and safety" according to older literature, though more recent evidence favors domperidone 2

Critical Safety Warnings

• Monitor closely for extrapyramidal symptoms including dystonic reactions, akathisia, and tardive dyskinesia 3
• Have diphenhydramine readily available for potential acute dystonic reactions 3
• Avoid in patients with seizure disorders or pheochromocytoma 1
• Use with caution in patients with GI bleeding or obstruction 1, 3
• Repeated doses can prolong QT interval and precipitate torsades de pointes 5
• Exercise caution in patients with impaired renal or hepatic function, elderly patients, and those with CNS depression 5

Comparative Considerations

• Domperidone (10-20 mg three times daily) may be preferable as it crosses the blood-brain barrier less than metoclopramide, reducing risk of central nervous system side effects in both mother and infant 2, 4
• Metoclopramide showed higher incidence of maternal side effects: 7/40 mothers on metoclopramide reported adverse effects versus 3/40 on domperidone in one trial 7
• No significant differences in maternal side effects were noted in the meta-analysis (RR 1.05 for metoclopramide vs 1.20 for domperidone) 4

Clinical Algorithm

1. First-line approach: Optimize non-pharmacologic interventions (frequent pumping/feeding, adequate hydration, rest)
2. If pharmacologic intervention needed: Consider domperidone 10-20 mg three times daily as first choice if available 8, 4, 9
3. If domperidone unavailable: Use metoclopramide 10 mg three times daily for 10-14 days maximum 1, 7
4. Monitor: Assess milk volume increase after 7-14 days and screen for adverse effects at each encounter 4, 7
5. Discontinue: If no response after 14 days or if adverse effects develop 3, 4