What medications are used to induce lactation?

Medications for Inducing Lactation

Domperidone and metoclopramide are the primary medications used to induce lactation, with domperidone being more commonly utilized despite not being FDA-approved for this indication in the United States. 1

Primary Galactagogue Medications

Domperidone

• Domperidone is the most commonly used pharmacological galactagogue, functioning as a dopamine receptor antagonist that stimulates prolactin release to increase milk production 2, 3
• Typical dosing ranges from 30-60 mg/day divided three times daily (10-20 mg three times daily), though doses up to 160 mg/day have been reported in practice 2
• Domperidone increases prolactin levels significantly (from baseline ~73 ng/mL to 223 ng/mL after 7 days) and can increase milk production from approximately 156 mL to 401 mL over 14 days 3
• Transfer into breast milk is minimal (mean 2.6 ng/mL with chronic dosing), considerably less than metoclopramide or sulpiride relative to therapeutic dosage 4

Metoclopramide

• Metoclopramide is also used as a galactagogue and may increase milk supply 1
• It is compatible with use in lactating women 1
• Has higher transfer into breast milk compared to domperidone 4

Critical Safety Considerations

Domperidone-Specific Warnings

• Domperidone is NOT FDA-approved for any human use in the United States and carries an FDA import alert and public safety warning due to associations with serious cardiac arrhythmias, QT prolongation, torsades de pointes, and sudden cardiac death 5
• Despite these warnings, domperidone is approved in some countries for gastrointestinal disorders (though not for lactation enhancement anywhere) and continues to be used off-label 5
• Side effects are common (48% of users) and dose-related, including weight gain (25%), headaches (17%), and dry mouth (13%), with 9% discontinuing due to adverse effects 2
• Higher doses (>61 mg/day) are associated with 73% incidence of side effects versus 38% at ≤30 mg/day 2

Clinical Efficacy Context

• Nearly 72% of mothers with perceived lactation failure can increase milk production through counseling on breastfeeding advantages and proper management alone, without pharmacological intervention 3
• Among those requiring medication, 45% of domperidone users report it as "very" or "extremely effective," with only 8% reporting no effectiveness 2
• Domperidone treatment resulted in 95% exclusive breastfeeding at hospital discharge versus 52.4% with placebo 3

Practical Prescribing Algorithm

If considering pharmacological lactation induction:

1. First, optimize non-pharmacological interventions including proper latch technique, frequent feeding/pumping schedules, and lactation consultant support 3

2. If medication is deemed necessary after counseling:

   • Start with domperidone 10 mg three times daily (30 mg/day total) 2, 3
   • Screen for cardiac risk factors including QT prolongation, electrolyte abnormalities, and concurrent QT-prolonging medications before prescribing 5
   • Consider baseline ECG in high-risk patients 5

3. Monitor response over 7-14 days with daily milk volume tracking 3

4. If inadequate response at 30 mg/day, may increase to 20 mg three times daily (60 mg/day), recognizing increased side effect risk 2

5. Typical treatment duration is 6 weeks (median from real-world data), though some require longer courses 2

Important Caveats

• The evidence base for domperidone efficacy remains limited in quality, with the FDA position being that available data "do not offset safety concerns from a public health perspective" 5
• Nearly 20% of users initiate domperidone in the first week postpartum, though optimal timing remains unstudied 2
• Ensure access to breast pump if any delay in infant feeding occurs, as domperidone may increase supply before infant can effectively remove milk 1
• The drug does not cross the blood-brain barrier, which theoretically improves its safety profile compared to other dopamine antagonists 4, 6