Increasing lactation

Domperidone

• Domperidone raises prolactin levels; which helps increase the production of breast milk
• usually started at a dose of 10mg (one tablet) three times a day
• milk supply should start to improve within 7 days and peak at 2-4 weeks
• once adequate breast milk supply is reached, the dose should be slowly reduced to avoid a drop in milk production
• if supply remains low, there is some evidence – though weak – that doubling the dose may help; but this should only be done under careful medical supervision
• side effects are uncommon but include headaches, abdominal pain, dry mouth and, even less commonly, a rash or trouble sleeping, depressed mood and headache. 
• most studies have investigated the effects of domperidone in mothers following preterm birth (birth at less than 37 weeks’ gestation) where their baby is admitted to a hospital neonatal unit. In these settings, domperidone was associated with a short-term increase in daily milk production of 90 millilitres per day. We assume domperidone works just as well in mothers with a full-term birth, but there’s no evidence to prove this

Very small amounts of domperidone pass into breastmilk. DaSilva ⁽¹⁶⁾ reported average milk concentrations ranged from 1.2 micrograms/L to 2.6 micrograms/L. in babies whose mothers had taken domperidone 10mg three times a day for 5 days. No adverse events were noted in mothers or children. Domperidone is subject to extensive first pass metabolism which accounts for the low transfer into breastmilk. The mean relative infant dose was 0.01% after a 30 mg daily dose and 0.009% at 60 mg.Hale quotes a relative infant dose range of 0.01% – 0.04%, well below the 10% regarded as significant.

When to avoid domperidone 

• where either mother or baby has any evidence of cardiac abnormalities and specifically arrhythmia 
• is receiving other medications known to prolong QT interval or potent CYP3A4 inhibitors e.g. quinolone antibiotics, ketoconazole (fluconazole may also be considered a risk), macrolide antibiotics, SSRI antidepressants, tricyclic antidepressants, salbutamol
• where severe hepatic impairment has been identified in mother or baby
• where either mother or baby has  high or low levels of potassium, or low levels of magnesium

Metoclopramide

Domperidone belongs to the same family of medicines as metoclopramide and works in a similar way. But they have very different side effects. Metoclopramide can cause central nervous system side effects such as fatigue, irritability, or depression. Side effects are much less likely with domperidone, so it’s the preferred medicine to boost breast milk supply.

Most studies have used metoclopramide in a dosage of 10 mg 2 or 3 times daily for 7 to 14 days. Some studies used a tapering dosage for the last days few of the regimen to avoid an abrupt drop in milk supply after drug discontinuation.

Herbal medicines

Research has been carried using fenugreek, milk thistle, blessed thistle and gingerwith no good quality evidence that they work - they have many side effects and interactions so should be avoided. 

References

https://www.breastfeedingnetwork.org.uk/domperidone/

https://theconversation.com/domperidone-can-boost-breast-milk-supply-heres-what-you-need-know-88648#:~:text=Domperidone%20works%20to%20raise%20levels,at%20two%20to%20four%20weeks.