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The use of Reglan to increase breastmilk supply

Professional Breastfeeding Information Sheet

Metoclopramide is 2-methoxy-5-chloroprocainamide (1). It is the prototype of the selective dopamine antagonists called substituted benzamides. Metoclopramide stimulates the motility of the upper gastrointestinal tract without stimulating gastric, pancreatic or biliary secretions. It increases the tone and amplitude of gastric contractions, relaxes the pyloric sphincter and the duodenal bulb, and increases peristalsis of the duodenum and jejunum, resulting in accelerated gastric emptying and intestinal transit. It has little, if any, effect on the motility of the colon or gallbladder. It also increases the resting tone of the lower esophageal sphincter. (2)

It's mode of action is not clear. Metoclopramide appears to sensitize tissues to the action of acetylcholine. It's antiemetic properties are the result of antagonism of central and peripheral dopamine receptors. Onset of action after a po dose is 30-60 minutes, with 85 % being excreted in the urine. It is 30 % protein bound with a high volume of distribution, indicating good tissue penetration.(2)

Metoclopramide induces the release of prolactin from the anterior pituitary by blocking dopamine's action as an inhibitor of prolactin secretion, and causes a transient increase in circulating aldosterone levels. (2) Prolactin levels have been measured at 3-8 times normal within 1 hour of a po dose and can remain elevated for up to 8 hours. (3)

Metoclopramide, (4-16) sulpiride, (17) chlorpromazine, (18) and thyrotropin-releasing hormone, (14, 19-20) have been shown to successfully induce lactation. Metoclopramide has been used preferentially due to its safety and relative lack of side effects when compared to the other known galactogogues.

About 10 % of all patients treated with metoclopramide report nervousness, somnolence, fatigue, and lassitude. Less than 1 % report insomnia, headache, bowel disturbances, and less than 0.2% report an acute dystonic reaction.(2) In studies where metoclopramide is used as a galactogogue, side effects are extremely rare. Kauppila (11) reported occasional tiredness, headache and nausea in the treatment group, and tiredness, dizziness and sweating in his placebo control group. No side effects were noted by Gupta (12) or Kauppila (8). Ehrenkranz (13) reported no side effects in 21 of 23 treated women, with one woman reporting diarrhea and nervousness, and another increased tiredness. Kaupplila (8) showed no change in maternal TSH, T3 or T4.

Metoclopramide is transferred into breastmilk. (6,21) Kauppila et al (21) reported it's concentration was generally higher in breastmilk than in maternal plasma. Although the estimated intake of metoclopramide was calculated at 1-5% of the recommended therapeutic dose for children (0.5 mg/kg/d), it was detected in the plasma of only one of the 5 neonates studied. No side effects were noted, and plasma thyrotropin remained within the normal range. Metoclopramide has been given directly to preterm infants to improve gastrointestinal function (22) and is commonly used in NICU's to treat gastroesophageal reflux .

Ertl (15) demonstrated that metoclopramide augmented milk production without having any effect on the prolactin and sodium concentration of human "mature" milk. The plasma prolactin of newborns of mothers treated with metoclopramide did not differ from the values of the control babies. deGezelle (10) noted a shift in amino acid composition occuring earlier in the treatment group suggesting that metoclopramide enhances the rate of transition from colostrum to mature milk. The effect of metoclopramide therapy on the composition of preterm human milk is not known.

Reglan®(Metoclopramide) is usually taken as a 10 mg tablet orally, three or four times a day for a week, then tapered off over the next week. Cost for 30 tablets is approximately $33 for the brand name Reglan® and $12-15 for the generic brand which is just as effective. Milk supply usually increases within 2-4 days of starting the medication and pumping 6-8 times per 24 hours.

It is essential the breasts be emptied, with a breastpump or by the infant, frequently and regularly, even at night.

References:

Schulze-Delvieu K: Metoclopramide. N Engl J Med 305: 28-33, 1981
Physicians' Desk Reference, 49th Ed, Medical Economics, Montvale, NJ, 1995
McNeilly AS, Thorner MO, Volens G et al: Metoclopramide and prolactin, Br Med J 2: 729, 1974
Sousa PLR, Barros FC, Pinheiro GNM et al: Reestablishment of lactation with metoclopramide. J Trop Pediatr Environ Child Health 21: 214, 1975
Guzman V, Toscano G, Canales ES et al: Improvement of defective lactation by using oral metoclopramide. Acta Obstet Gynecol Scand 58(1): 53-55, 1979
Lewis PJ, Devenish C, Kahn C: Contolled trial of metoclopramide in the initiation of breast feeding. Br J Clin Pharmacol 9: 217-219, 1980
Tolino A, Tedeschi A, Farace R et al: The relationship between metoclopramide and milk secretion in puerperium. Clin Exp Obstet Gynecol 8(3): 93-95, 1981
Kauppila A, Kivinen S, Ylikorkala O: Metoclopramide increases prolactin release and milk secretion in puerperium without stimulating the secretion of thyrotropin and thyroid hormones. J Clin Endocrinol Metab 52(3): 436-439, Mar 1981
Kauppila A, Kivinen S, Ylikorkala O: A dose response relation between improved lactation and metoclopramide. Lancet 1(8231): 1175-1177, May 30, 1981
deGezelle H, Ooghe W, Thiery M et al: Metoclopramide and breast milk. Eur J Obstet Gynecol Reprod Biol 15(1): 31-36, Apr 1983
Kauppila A, Anunti P, Kivinen S et al: Metoclopramide and breast feeding: efficacy and anterior pituitary responses of the mother and child. Eur J Obstet Gynecol Reprod Biol 19(1): 19-22, Jan 1985
Gupta AP & Gupta PK: Metoclopramide as a lactogogue. Clin Pediatr 24(5): 269-272, 1985
Ehrenkrantz RA, Ackerman BA: Metoclopramide effect on faltering milk production by mothers of premature infants, Pediatrics 78: 614, 1986
Liu JH, Lee DW and Markoff E: Differential release of prolactin variants in postpartum and early follicular phase women. J Clin Endocrinol Metab 71(3): 605-610, Sept 1990
Ertl T, Sulyok E, Ezer E et al: The influence of metaclopramide on the composition of human breast milk. Acta Paediatr Hung 31(4): 415-422, 1991
Budd SS, Erdman SH, Long DM et al: Improved Lactation with metoclopramide. A case report. Clin Pediatr 32: 53, 1993
Aono T, Aki T, Koike K, et al: Effect of sulpride on poor puerperal lactation. Am J Obstet Gynecol 143: 927-932, 1982
Brown RE: Relactation: An overview. Pediatrics 60: 116-120, 1977
Tyson JE, Perez A, Zanartu J: Human lactational response to oral thyrotropin releasing hormone. J Clin Endocrinol Metab 43: 760-768, 1976
Bose CL, D'Ercole J, Lester AG et al: Relactation by mothers of sick and premature infants, Pediatrics 67: 565, 1981
Kauppila A, Arvela P, Koivisto M et al: Metoclopramide and breastfeeding: transfer into milk and the newborn, Eur J Clin Pharm 25(6): 819-823, 1983
Meadow WL, Bui KC, Strates E et al: Metoclopramide promotes enteral feeding in preterm infants with feeding intolerance, Dev Pharmacol Ther 13: 38, 1989
Lawrence RA: Breastfeeding: A Guide for the medical profession, 4th Ed. Mosby, St. Louis, MO, 1994, pp740-1 (table)

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