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Domperidone Part 2

When domperidone was being used for babies (and now that cisapride is off the market, it is being used again), it was common for the babies to be on the medication for several months. Since the amount of domperidone that gets into the milk is very small indeed, from the baby’s point of view, there should be no issue in the mother taking it to increase milk supply for several months. Our experience with this drug is that short-term side effects are very few and almost always very mild. Worldwide experience with domperidone over at least two decades suggests that long-term side effects also are rare. Some of the mothers in our clinic, breastfeeding adopted babies, have been on the medication for 18 months without any apparent side effects. As mentioned in handout #19a Domperidone-1, patients using domperidone for stomach disorders may be on it for many years. I hope you won’t need domperidone for very long, but if it’s necessary and helpful, stay on it.

How long does it take for domperidone to work?

It depends on the situation. In a situation where the mother had had a good milk supply, but it decreased for some reason (e.g. going on the birth control pill, see handout #25 Slow Weight Gain After the First Few Months), domperidone often works very rapidly to increase the milk supply. Often, within a day or two the mother is seeing a difference (and so does her baby). But this is not always so, and in many situations, it may take a week or more for the mother to start getting an effect. On occasion, we have had mothers only starting to get an increase in their milk supplies a month or more after starting to take it. Therefore, we generally recommended that the mother take the domperidone for at least six weeks in order to be sure whether it has worked or not.

It is our impression that domperidone works best after the first few weeks after the mother has given birth (usually after about four weeks). This has not been proved, but there are theoretical reasons why it may be so. For this reason, we have often waited to prescribe it until the baby is at least three weeks, mainly because we did not want the mother to become discouraged if she did not see any rapid increase in her milk supply. But if you keep this in mind, I have no problem prescribing it before four weeks after the birth of the baby.

How do I know how long to take domperidone?

Usually, we ask the mother take it for two weeks and then re-evaluate the situation. There are several possibilities.

• The milk supply has increased substantially, to the point where there is no longer a consideration of using supplements, or the mother has been able to stop supplements with the baby continuing to gain well on breastfeeding alone.
• The milk supply has increased to a point that the mother feels is satisfactory. For example, she may still need to supplement, but the baby does not fuss any more at the breast and drinks contentedly.
• There has been little or no effect with the Protocol to Increase Breastmilk Intake by the Baby and the domperidone. Often waiting or increasing the dose may help.

In the first situation (but not necessarily always in that situation), we may suggest the mother start weaning herself from the domperidone in this way:
1. Most mothers are taking three tablets three times a day. When you are ready to start weaning from the domperidone, drop one pill, so that now, instead of nine pills a day, you will be taking eight..
2. Wait four or five days, a week if you wish. If you see no change in your milk supply, drop another pill.
3. Wait another four or five days. If you see no change in your milk supply, drop another pill.
4. Continue in this way until you are down to no pills a day. If there has been no decrease in your milk supply, or if there has been a small decrease that does not affect the breastfeeding and baby’s weight gain, that’s just what we hope to have happened, and many mothers manage this.
• If, however, your supply diminishes significantly, return to the previous effective dose and do not drop any pills for a couple of weeks at least.
• If you are keen to go off the domperidone, after a couple of weeks on the same dose, start dropping a pill a day, as in step 1 above. Some mothers, who were not able to get off the domperidone with steps 1-4 above the first time, can do it the second or the third time.
• You may find that you have to continue a certain dose to maintain your milk supply. But following steps 1-4 above will get you to the lowest effective dose.

It is possible, however, that after two weeks, you are not where you want to be. In that case, you should continue using the domperidone. If you are still not where you want to be after six weeks of domperidone, it is time to think some more about the domperidone. If you are supplementing, and have managed to reduce the amount of supplement from 14 ounces to 10 ounces, is it really worth taking a drug in order to do this? If you feel it is, then continue with the domperidone, but try weaning the number of pills down to minimum number that maintain your milk supply, as above. If you do not feel it is worth it, try weaning down as above, and if you don’t see any change once you get to no pills a day, fine. However, if you do notice a real change in the milk supply as you lower the dose, maybe the domperidone is more effective than you had thought (remember, after six weeks, your baby is significantly heavier, and it may be that instead of needing 14 ounces without domperidone, the baby might actually need 20 ounces to maintain good weight gain, in which case the domperidone is actually doing something).

Remember: Before using domperidone, the breastfeeding should be fixed, and as quickly as possible. This means:
• Getting the best latch possible. This alone may result in the baby getting enough milk.
• Using compression to continue milk intake by the baby.
• “Finish” one side before offering the other (see protocol for increasing breastmilk intake by the baby for an explanation on how to know the baby is getting milk)
• Do not limit the baby to one side if the baby is not getting enough. Switch to the other side once the baby is no longer getting milk even with the compression.
• Switch back and forth, as long as the baby is getting good amounts of milk.
• See the protocol for increasing breastmilk intake by the baby.

See the handout protocol for increasing breastmilk intake by the baby , and handout #25, Slow Weight Gain After the First Few Months. See also the website www.thebirthden.com/Newman.html for videos on how to latch a baby on, how to know the baby is getting milk, how to use compression, how to use a lactation aid, as well as information sheets on breastfeeding.

Questions? (416) 813-5757 (option 3) or drjacknewman@sympatico.ca or my book Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA)

Handout #19b. Domperidone-2. January 2005
Written by Jack Newman, MD, FRCPC. © 2005

This handout may be copied and distributed without further permission,
on the condition that it is not used in any context in which the WHO code on the marketing of breastmilk substitutes is violated