Supporting breast feeding : don’t dump the domperidone.

Breast is best, as I say repeatedly, and mother’s breast milk is the best of the lot; we should do all we can that is effective and safe to ensure that mothers of preterm babies can supply adequate milk for their infants.

(Picture from the Sick Kids website)

For several years I have prescribed domperidone for some mothers, currently in collaboration with our excellent group of lactation consultants, in the hope that the apparent short term augmentation was a real effect. I was not that sure that the impact was enough, or safe enough, but it seemed to work, and I thought we needed better data.

Last year a publication from a Canadian multicenter trial Asztalos EV, et al. Enhancing Human Milk Production With Domperidone in Mothers of Preterm Infants. Journal of human lactation. 2017;33(1):181-7. showed an improvement in milk output with the drug. The study was stopped early because of the difficulties in enrolment, and only 90 of the 560 mother sample size was enrolled. The study enrolled mothers 8 to 21 days after delivery of a baby of less than 29 weeks, who were not producing enough milk to supply 100% of their baby’s needs (estimated at 150 mL/kg/d). They received either domperidone 10 mg 3 x per day, or placebo for 14 days, and then another 14 days of active drug in both groups. On day 14 there was a higher proportion of mothers in the active group who had more than a 50% increase in milk production (78% vs 58%). By day 28, when all were receiving active drug, there were no longer any differences between groups. No significant adverse effects were found.

The domperidone works, then, and promotes breast milk production, with an average of over a 200% increase in volume; the absolute number of mLs difference was not enormous. The results suggest to me that a mother who has been evaluated by a lactation specialist, and nevertheless continues to produce less milk than her baby needs between 1 and 3 weeks after delivery, and who is prepared to take a medication, then it will likely increase the proportion of her milk that the baby receives. If she isn’t sure about taking the drug she could wait another 14 days, and then be re-offered the medication, if she is still having problems, as it will probably still work.

Just in print is a systematic review of domperidone for this indication (Grzeskowiak LE, et al. Domperidone for increasing breast milk volume in mothers expressing breast milk for their preterm infants: a systematic review and meta-analysis. BJOG. 2018;125(11):1371-8) of which the Asztalos trial is the largest. The review is accompanied by a video summarizing the results, how very 21st century for those with short attention spans!

The total data set is less than 200 mothers, unfortunately, so the power to detect adverse events is low, however, a modest increase in milk production among mothers of preterm infants, all of whom were enrolled because of low milk supply, was consistent among the studies. The actual volumes involved were enough to have a valuable impact on the proportion of maternal milk received by the babies. No adverse effects in either mother or baby has been shown in the 5 included trials.

So don’t dump the domperidone!

About Keith Barrington

I am a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal
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