Indications for Galactogogues
Common indications for galactogogues are adoptive nursing (induction of lactation in a woman who was not pregnant with the current child), relactation (reestablishing milk supply after weaning), and increasing a faltering milk supply because of maternal or infant illness or separation. Mothers who are not directly breastfeeding but are expressing milk by hand or with a pump often experience a decline in milk production after several weeks. One of the most common indications for galactogogues is to augment a declining milk supply in mothers of preterm or ill infants in the neonatal intensive care unit.
Procedure
- Before using any substance to try to increase milk supply, a full evaluation of current maternal milk supply and effectiveness of milk transfer is imperative. Attention must be directed to the evaluation and augmentation of frequency and thoroughness of milk removal. This can be accomplished through increased frequency and duration of breastfeeding (if the infant has been shown to be effective at emptying the breasts) or pumping. A full-size, automatic cycling breast pump, capable of draining both breasts ("hospital grade") at the same time is recommended, if available. Problems such as inappropriate timing and duration of feedings, inappropriate supplementation, mother-infant separation, ineffective latch, and inadequate milk transfer should be corrected.
- Women should be informed of any data (or lack thereof) regarding the efficacy, safety, and timing of use of galactogogues. With the exception of adoptive nursing, where galactogogues are started before the birth of the baby, there is no research to suggest that starting galactogogues within the first week postpartum is efficacious.
- Mothers should be screened for contraindications to the chosen medication or substance and informed as to possible side effects. Although a lactation consultant may recommend the medication or herb, it is the physician's responsibility to prescribe medications and follow the mother and infant.
- The physician who prescribes the medication is obligated to follow, or to ensure appropriate follow-up, of both mother and infant regarding milk supply and any side effects. In practice, many times it is the nurse practitioner, pediatrician, or neonatologist who is asked to prescribe a galactogogue and not the obstetrician-gynecologist. As is commonly found when dealing with lactation, family physicians are ideally situated to manage this issue.
- Although short-term use (1 to 3 weeks) has been evaluated for some of these substances, long-term use has not been studied. Anecdotal reports suggest no increase in side effects with the most commonly used medications (metoclopramide, domperidone, fenugreek), but long term effects on both mother and infant are unknown.
Specific Galactogogues
Many medications, foods, and herbal therapies have been recommended as galactogogues (see the section titled "Specific Galactogogues" in the original guideline document for information on metoclopramide, domperidone, sulpiride, chlorpromazine, human growth hormones, thyrotrophin-releasing hormone, and herbal/natural galactogogues). The medications used often exert their effects through antagonism of dopamine receptors, resulting in increased prolactin. In many cases, the mechanism(s) of action are unknown.
Conclusions
Of the substances used to induce, maintain, or augment milk production, domperidone and metoclopramide appear to be the most clinically useful. Prior to the use of any galactogogue, evaluation and correction of any modifiable factors such as frequency and thoroughness of breast emptying should be addressed. Medication should never replace evaluation and counseling on modifiable factors or reassurance when appropriate. As with any medication given to lactating women, close follow-up of both mother and baby is essential.
