Pharmacological management of low milk supply with domperidone: separating fact from fiction

To the Editor: After publication of our peer-reviewed perspective article on the safe and effective use of domperidone in the management of low milk supply,1 we are disappointed to have been informed that the Australian medicines handbook (AMH) has removed lactation stimulation as a recognised off-label indication for domperidone (as well as metoclopramide). It appears that this change could be a kneejerk response to recent regulatory warnings, despite these being highlighted as not being of relevance to most breastfeeding women.1,2 These changes carry with them the significant potential to create confusion among prescribers and the public.

We would like to re-emphasise the points we have made previously that further restrictions regarding the use and availability of domperidone do not appear to be warranted; they risk subjecting women to additional emotional trauma and are not in the interests of the immediate and long-term health of breastfeeding women and their babies.1,2 There is absolutely no evidence that domperidone places breastfeeding mothers at increased risk of severe cardiac events, whereas, in contrast, there is evidence of the significant benefits to be gained from the use of domperidone in supporting breastfeeding. Domperidone has been used widely in clinical practice for women experiencing low milk supply,3 with no reports of significant adverse effects.

We also re-emphasise our previous practice points regarding the importance of adequately screening women for factors that may place them at increased risk of cardiac arrhythmia, should this be of concern.

It is clear that domperidone is not a magic bullet for adequate milk production in breastfeeding women. Non-pharmacological management options are the mainstay of treatment, with medications only to be considered as a last resort, and always in addition to these management strategies.4 There is no easy fix when it comes to supporting women who are struggling with low milk supply, but when used appropriately, domperidone can be a very safe and effective treatment option.