The Protocols for Induced Lactation — A Guide for Maximising Breastmilk Production
By Jack Newman, MD, FRCPC and Lenore Goldfarb, PhD, CCC, IBCLC, ALC
Based on the original Induced Lactation Protocol conceived and published by Jack Newman MD
The Newman-Goldfarb protocols were developed from information published in Dr. Newman’s book “Dr. Jack Newman’s Guide to Breastfeeding” (Harper-Collins, 2000). In the US the title is “The Ultimate Breastfeeding Book of Answers” by Dr. Jack Newman (Prima Publishing, 2000).
Domperidone (Motilium) is a drug that, as a side effect, increases breastmilk production by increasing prolactin (a hormone involved in making milk) secretion from the pituitary gland. Domperidone is generally used for problems with the gastrointestinal (GI) tract, or gut. It has not been released in Canada for increasing milk supply, but this does not mean it cannot be prescribed for this reason, just that the manufacturer does not support this use. There are many studies that show that domperidone works to increase milk supply and is relatively safe to use.
Metoclopramine (Maxeran, Reglan) is also known to increase milk supply, but it has frequent and unpleasant side effects (like fatigue, irritability, and depression). Domperidone has fewer side effects and is better tolerated by most people – this is because it does not enter the brain in significant amounts. Note, even if you have “enough milk”, increasing the milk supply also increases the flow of milk. This is helpful for many situations, including sore nipples, fussiness at the breast, and refusing to latch.
Domperidone should not be the only approach to address breastfeeding challenges. It should be used along with other strategies to increase milk supply and improve the breastfeeding situation. See the other information sheets at www.ibconline.ca, including “Protocol to Increase Breastmilk Intake” and “Late Onset Decreased Milk Supply or Flow”.
Generally, we start with 30 mg (three 10 mg tablets) three times per day – a total of 9 tablets per day. In some situations we will go as high as 40 mg four times per day (or, for convenience, 60 mg once per day and 50 mg twice per day). The pharmacist may instruct you to take each does 30 minutes before eating, but that is because of its usual use for digestive problems. Taking domperidone on an empty stomach does allow it to be better absorbed, but it is not necessary to do this for it to work to increase breastmilk production. Spread the doses out throughout the day and take it when it is most convenient for you.
After starting domperidone, it often takes three or four days before you notice any effect. It usually takes about two weeks to get a maximum effect, but some find it takes even longer. It may also be important to remember that domperidone usually only begins to work three or four weeks after birth, but sometimes earlier. Sometimes the herbal remedies work best early on (see the information sheet, “Herbal Remedies for Milk Supply” at www.ibconline.ca).
As with all medications, side effects are possible. There is no such thing as a 100% safe drug. However, in our clinical experience, side effects in the breastfeeding parent are very uncommon. Some people may experience headache, dry mouth, abdominal cramps, weight gain/increased appetite, and alteration of menstrual periods (usually stopping them, if they have resumed; breakthrough bleeding is also possible). Most of those who experience side effects find they disappear after a few days.
The amount of domperidone that gets into the breastmilk is very small and side effects in the baby should not be expected. Domperidone is sometimes given to babies with reflux and the amount they get through the milk is a very small percentage of what they would get if they were treated with domperidone directly.
As a general recommendation, continue taking domperidone until your baby is well established on solid foods. Some people are able to stop domperidone sooner than this, if the breastfeeding challenges have resolved and things have been going very well for a least a few weeks. Some people continue domperidone for many months and some beyond a year. Worldwide experience with domperidone over at least 20 years suggests that long-term side effects are uncommon.
When you are ready to stop taking domperidone, you should gradually wean off it. This is to prevent a possibly significant drop in your milk supply and side-effects (like anxiety and loss of appetite) that may occur if domperidone is stopped suddenly.
To wean from domperidone, decrease your daily dose by one tablet per day per week (so, for example, if you are taking 30 mg three times per day, or nine tablets per day, you would first decrease to eight tablets per day). After seven days, if you see no decrease in your milk supply, decrease the daily dose by one tablet again. Continue in this way until you have completely stopped the medication. If, at any point during the weaning process, you notice your milk supply decreasing significantly or your previous breastfeeding challenges (or new ones) arise, return to the previous effective dose. Try resuming the weaning process again after a couple of weeks.
In 2004, the Federal Drug Administration (FDA) in the United States put out a warning against using domperidone because of possible heart-related side effects. However, these side effects occurred only when the drug was given intravenously to otherwise very sick patients, taking many other drugs.
In 2012, Health Canada endorsed a warning put forth by the company who manufacturers domperidone. This warning was about oral doses higher than 30 mg per day and the risk of heart-related side effects. However, the research cited to support this warning involved patients with an average age of over 70 years old, many of whom had pre-existing health conditions. These warnings do not apply to the population to whom we prescribe domperidone (typically younger, healthy women) and we have continued to prescribe it to breastfeeding parents as we have for more than 30 years. We have treated thousands of people with domperidone and we are not aware of any one of them experiencing heart-related side effects due to domperidone. Also, as of 2015, Health Canada had never received any reports of serious heart-related adverse effects in anyone of childbearing age taking domperidone.
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The information presented here is general and not a substitute for personalized treatment from an International Board Certified Lactation Consultant (IBCLC) or other qualified medical professionals. This information sheet may be copied and distributed without further permission on the condition that it is not used in any context that violates the WHO International Code on the Marketing of Breastmilk Substitutes (1981) and subsequent World Health Assembly resolutions. If you don’t know what this means, please email firstname.lastname@example.org to ask!
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