Domperidone for Breast Milk Supply
Domperidone is effective and safe for increasing breast milk supply in lactating women with insufficient milk production, with low levels transferred to breast milk due to first-pass metabolism, and should be used after optimizing non-pharmacologic interventions. 1, 2
Mechanism and Efficacy
Domperidone functions as a dopamine D2 receptor antagonist that stimulates prolactin release, thereby increasing milk production. 3 The drug demonstrates a statistically significant 74.72% relative increase in daily milk production compared to placebo (95% CI = 54.57-94.86, P < 0.00001). 4
Evidence from High-Quality Trials
- A 2021 randomized, double-blinded, placebo-controlled trial showed breast milk production increased from baseline 156 ± 141.1 mL to 400.9 ± 239.2 mL in the domperidone group versus 175.8 ± 150.7 mL to 260.5 ± 237.5 mL in placebo (p < 0.01). 5
- Prolactin levels increased significantly from 72.85 ng/mL to 223.4 ng/mL on day 7 in the domperidone group (p = 0.005) versus no significant change in placebo. 5
- 95% of infants in the domperidone group were exclusively breastfeeding at hospital discharge compared to 52.4% in placebo (p = 0.008). 5
Clinical Algorithm for Use
Step 1: Optimize Non-Pharmacologic Interventions First
Before prescribing domperidone, ensure the following have been maximized: 2
- Frequent feeding or pumping (at least 8-12 times per 24 hours)
- Proper latch technique verification
- Adequate maternal hydration and nutrition
- Skin-to-skin contact
Step 2: Exclude Medical Causes
Rule out underlying conditions causing low supply: 2
- Retained placental fragments
- Thyroid dysfunction (hypothyroidism)
- Insufficient glandular tissue
- Medications that suppress lactation
Step 3: Dosing Protocol
- Standard dose: 10 mg orally three times daily for 14-28 days 5, 6
- Ensure access to a breast pump if any delay in infant feeding occurs, as milk supply may increase before the infant can effectively remove the increased volume 1, 2
Safety Profile
Maternal Safety
- No adverse maternal events were observed in systematic reviews of randomized controlled trials. 4
- Minor adverse effects reported in Japanese cohort included mild headache and abdominal pain in 2 of 10 mothers, both resolving promptly. 6
- No cardiac adverse events (QT prolongation, cardiac arrest) were observed in clinical trials. 6
Infant Safety
Domperidone levels in breast milk are low due to extensive first-pass hepatic and intestinal metabolism when taken orally. 1 This pharmacokinetic profile makes it compatible with breastfeeding, as minimal drug reaches the infant through milk transfer.
- No neonatal adverse effects were reported in any randomized controlled trials. 4
- The drug is used safely in Canada, Australia, and the United Kingdom. 6
Important Caveats
Pre-Treatment Screening
- Obtain baseline electrocardiogram before initiating therapy to rule out pre-existing QT prolongation, particularly given FDA warnings about cardiac risks (though not observed in clinical trials). 6
- This precaution is especially important for women with cardiac risk factors or those taking other QT-prolonging medications.
Realistic Expectations
71.7% of mothers with perceived lactation failure were able to increase milk production through counseling and proper breastfeeding management alone without pharmacological intervention. 5 This underscores the critical importance of exhausting non-pharmacologic strategies first.
Guideline Recognition
The American College of Obstetricians and Gynecologists identifies domperidone as a primary galactagogue medication, though it is not FDA-approved for this indication in the United States (unlike metoclopramide, which is FDA-approved). 2 Despite lack of FDA approval for lactation enhancement, domperidone is more commonly utilized than metoclopramide in clinical practice. 2