Can Reglan (metoclopramide) be used to aid in lactation?

Metoclopramide (Reglan) for Lactation Enhancement

Yes, metoclopramide can be used to aid lactation and is compatible with breastfeeding, though recent evidence questions its actual effectiveness in increasing milk volume despite raising prolactin levels. 1

Guideline-Based Recommendations

Metoclopramide is recognized as a galactagogue that may increase milk supply and is explicitly compatible with use in lactating women. 2 The American Academy of Pediatrics and American College of Obstetricians and Gynecologists identify both metoclopramide and domperidone as the primary medications used to induce lactation, with metoclopramide being FDA-approved (unlike domperidone in the United States). 1

Mechanism and Physiologic Effects

• Metoclopramide works by blocking dopamine receptors, which removes the inhibitory effect on prolactin secretion, thereby elevating serum prolactin levels. 3
• Studies consistently demonstrate significant increases in maternal serum prolactin concentrations with metoclopramide administration. 4, 5
• The drug is also used as an antiemetic and prokinetic agent, which explains its presence in anesthesia guidelines for breastfeeding women. 2

Evidence on Effectiveness: A Critical Discrepancy

There is a significant disconnect between prolactin elevation and actual milk production:

• The most recent systematic review and meta-analysis (2021) found that metoclopramide did NOT increase milk volume compared to control groups, despite raising prolactin levels. 4 This is the highest quality evidence available and directly contradicts older studies.
• Older studies from 1979-1981 reported increases of 42.5-50 ml per feed with doses of 10-15 mg three times daily. 5, 6
• Historical literature from 2002 identified metoclopramide as "the galactogogue of choice due to its documented record of efficacy." 3

This represents a critical pitfall: elevated prolactin does not necessarily translate to increased milk production in clinical practice. 4

Dosing and Duration

• Effective doses in older studies were 10-15 mg three times daily (30-45 mg/day total). 5
• Lower doses of 5 mg three times daily did not stimulate prolactin or milk secretion. 5
• Treatment duration should not exceed 12 weeks due to risk of tardive dyskinesia. 7
• The FDA label explicitly warns that "You should not take metoclopramide for more than 12 weeks." 7

Safety Profile and Critical Warnings

The most serious risk is tardive dyskinesia (TD)—irreversible abnormal muscle movements that may not resolve even after stopping the medication: 7

• Risk increases with longer duration of use, higher doses, older age (especially women), and diabetes. 7
• TD manifests as uncontrolled movements: lip smacking, tongue protrusion, facial grimacing, and limb movements. 7
• Other extrapyramidal reactions (dystonia, akathisia) can occur, particularly within the first 2 days of treatment. 7

Additional safety considerations:

• Depression, suicidal thoughts, and suicide have been reported with metoclopramide use. 7
• The drug is excreted in breast milk, though no adverse effects in infants were observed in studies. 4, 5
• Sedation is common and may impair ability to drive or operate machinery. 7
• Caution is needed in patients with hypertension, as metoclopramide releases catecholamines. 7

Infant Safety

• No significant adverse events in breastfed infants were reported in clinical trials. 4, 5
• The FDA label states "Caution should be exercised when metoclopramide is administered to a nursing mother" and notes the drug is excreted in human milk. 7
• Ensure access to a breast pump if any delay in infant feeding occurs, as increased supply may develop before the infant can effectively remove milk. 1

Clinical Algorithm for Use

Given the conflicting evidence, metoclopramide should be considered only after:

1. Optimizing non-pharmacologic interventions (frequent feeding/pumping, proper latch, adequate maternal hydration and nutrition)
2. Excluding medical causes of low supply (retained placental fragments, thyroid dysfunction, insufficient glandular tissue)
3. Counseling the patient that recent high-quality evidence shows no improvement in milk volume despite prolactin elevation 4
4. Discussing serious risks of tardive dyskinesia, especially with use beyond 12 weeks 7
5. Considering domperidone as an alternative if available, as it has less CNS penetration (though not FDA-approved in the US) 1, 3

If prescribing metoclopramide:

• Start with 10 mg three times daily (avoid 5 mg doses as ineffective) 5
• Limit duration to the shortest time possible, never exceeding 12 weeks 7
• Monitor closely for extrapyramidal symptoms, particularly in the first 48 hours 7
• Discontinue immediately if any involuntary movements develop 7

Key Pitfall to Avoid

Do not assume that elevated prolactin equals increased milk production. The most recent meta-analysis demonstrates this assumption is false in clinical practice. 4 The subjective perception of improvement (89% of women reported "good effect" in one study) may reflect placebo effect, as 24% of placebo recipients also reported good results. 5