Domperidone….or Domperidon’t?

In this episode of The Milk Minute, we're tackling a topic that’s been on a lot of your minds: Domperidone. We’ll break down how this medication works, why some women use it to boost milk supply, and what the latest research says. We’ll share personal stories, answer your questions, and give you the scoop on what to consider if you're thinking about Domperidone. Tune in to learn all about the wonder drug!

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Listener Question: Can you remind me how many IUs of vitamin D3 I should be taking to properly supplement my breastfeeding baby?

Mentioned in this episode:
Ep. 31- Vitamin D: How to supplement and Why we need to

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Transcript

Welcome to the Milk Minute Podcast, everyone. Hello, good morning. I'm giving you all a gift today. Is it morning? It might be morning for you. It's not actually morning to say it. I'm giving you all a gift today.

Okay. Me? Not you. All of the listeners, because for the past four years now, you've been asking for an episode on Domperidone. Oh, praise Jesus. Now we have somewhere to link it back to when people message us and ask us about this wonder drug. Today we are going to talk about this medication, and I'm actually, I'm not happy about it, but I hope you are.

I mean, this is a gift for me because it does, You know, instead of me trying to recreate the wheel and explain this again, I can just hand them a pamphlet that has a QR code to this podcast episode. And you're like, please listen to episode 213. Please. Like the short answer today is no, I can't get that for you.

And listen to this podcast. Here's the long answer. Okay. But I, I mean, it's, it's time it was overdue and I, Usually listen to you guys suggestions, but I've been really resistant on this one. I love that you have this whole shit list of podcast episode ideas, and you've just been knocking them off this past year.

You're like, I'm gonna hit all these ones that I've been avoiding for four years. I know I really do. I've, it's, if you like, I don't know, there's a trend on TikTok of like showing your notes app, like girls notes apps, you know, mine is just podcast shit and grocery lists. Mine's, yeah, shit to do, stuff to remember, a fun place to hang out.

It's a lot of podcast stuff, because I'll just think randomly of it when I'm like in the grocery store and I'm like, oh, oh, okay, episode on this, yeah, let's do that. Well, I'm excited for this one. Before we get into it though, tell me how many babies you've been having lately? A lot. I've had a lot of babies.

Actually, what I, okay. Okay. So. I was feeling a little burnt out, especially at the end of last year because I, you know, as you do in this business, you'll go like for months and months with nothing going wrong and then have like three or four really shitty bursts in a row that are like all transfers and we're like, still everything is fine, everything's fine in the end, takes it out of you.

But there's just no, like, I don't know. A lot of the time, even if a birth is hard at the end, I can leave and be like, I did a good job. Everyone did a good job. Everyone's happy. I'm happy. That's not always how they end. And I had a bunch in a row that were really hard. Like that, where I just left feeling shitty, feeling like I could have done better, even if I couldn't have, you know?

Mm hmm. And so I decided to start, like, processing births differently, because I knew I had so many coming up this year, and if I wasn't, like, Engaging in an organized process post birth, I was just gonna like totally burn out. Like emotionally? Yeah, yeah. And like with like a ritual, you know what I mean?

Like doing the same thing every time. So what I started to do is to track them more visually for myself. Because I'm a very visual processor. And just like charting and then like obsessively thinking about things is not, it's not good for me. So I started doing things like keeping a little bead jar of like one bead per baby.

I have seen that on Instagram, it's very satisfying. Those videos do very well. And I started putting up footprints from all babies whose parents consent on the wall in my office. Which is so cute to just like watch it grow. Month by month, you know, and because I was just like journaling and just doing a like a little entry like, oh, birth number 124, you know, boy, this weight, whatever, but it wasn't like, it's nice to have that for statistics, basically, but that's it.

It wasn't helping me process it. And like keeping a visual log. Of what I'm doing really helps when it's overwhelming, because it's been overwhelming the last few months. I wonder why that happens, though. Why, like, all of a sudden you get this wave of complicated. Or it's, a lot of times it's weird, it'll be like the same complication over and over.

Oh, that truly does happen to me. Like, a few weeks ago, I had two births in a row that were transfers, hadn't had a transfer in months. You know, and they were both for malpositioning, both got stuck at literally like same station, same dilation. And I was like, am I like living in a simulation? Yeah, is it me?

Did I malposition your baby? Right? Like, did I, you know, and I really did have to take time to look back and be like, did I even tell them the same exercises prenatally? Like, you know, nothing was, there was actually almost no overlap in their histories and anything, but I just, it's, like, times like that that I'm like, okay.

I am, no matter how late it is, going to like drive by my office on the way home and take these little footprints and put them on the wall and take a step back and be like, okay, this is fine. You know, like look at the accumulation of my work instead of focusing on The one birth that was really challenging.

Yeah, that is a really good way of taking the 30, 000 foot view of the journey. Because you can get really bogged down in the day to day to the point where you're like, am I even making a difference? Am I even a person? It's like existential questions abound. And I, I mean, I definitely feel that I think the difference though, in what you do and what I do is that, and it's not, I don't know, I guess, When you have, like, one patient for 20 hours, you know, that is a lot different than having 20 patients in a day.

Well, we have, like, different flavors of monotony. You know what I mean? Yes. Like, for me, it's, like, the drudgery of, like, being in the same place doing the same thing can get to me. For you, it's, like, Groundhog Day every 30 minutes. Right. Sometimes. But to be honest with you, even in lactation, it's just like a different, every visit is so different.

So I almost have to like recreate the energy 20 times in a day, whereas yours, the energy just drains like a, yeah, like a sieve, you know, like people are a little more understanding at a birth. If we have been there for like 30 hours that I'm like, Hey, I'm at the bottom of my barrel. You too. We're all there.

We're all in the same place. Yeah. Pizza? Yeah. Yeah. Let's try to regroup everybody. Oh my gosh. Yeah. I don't know. And then it's like a blessing though, in a lot of ways, because when you, When you give all of that and you give all of yourself it does feel good in a way because you're like, yeah I did that like I gave my all today and then you have to think about like, how can I recharge myself?

How can I fill myself back up? And that's the piece that I think we miss a lot, especially when we have small kids So we don't have the ability to like be brand new again the next day and over time It just kind of like chips away at you. Well question for you Because our work's a little different.

Is part of that drain on you, like, that you're missing the outcome? You know, cause you don't get to see the happy outcome of every single case. Some people see you once and never come back. Honestly, not usually. Yeah. Because, I mean, I think I'm one of the luckiest healthcare providers out there, and I don't mean to, like, toot my own horn, but Toot it!

This is, we, this is our podcast. Yeah. Toot your horn. I can't, there's been, like, Maybe one person in the past year that I've only seen one time. Oh, nice. Like everybody comes back, even if they're not breastfeeding anymore. Because I say from day one, I'm like, I don't care if you breastfeed or not. Like whatever you want, if you decide to switch to formula, Please don't disappear.

Let me help you with that. So I think just like the tone of the office, we have a lot of moms that come for primary care now as well. Yeah, I'm so proud of you for adding that, by the way. And thank you. And we're doing more procedures now, so like IUDs we're doing a lot of. Oh yeah, I'm trying to get Heather to cut a cyst out of my head.

I will. I want to do it. I just, I don't want to be the only one here. It's on my scalp. It's not that, it's not that deep. It's in our eyeball. I don't do eyeballs. No, it would be, maybe we'll film it if we do it. And we can put it on Patreon. Oh God, the, the Pimple popping people are going to be like, yeah, let's do it.

How many of you guys are pimple popping people? Yeah. Be truthful. What does your FYP look like? What's FYP? It's your, oh, you don't TikTok. It's the like automatically algorithm generated videos that come up. Oh, anyway, sorry. I just blacked out there for a second. But yeah, no, I've been really enjoying the procedures.

So like, for example, Friday, I did an IUD. I did a medical weight loss management. I did four lactation clients, all of them completely different cases. And then fun. And then I did an IUD. So it was like very random and different. And so that's a lot places to make your brain go. But. I don't know. It was, it was good.

I don't think a lot of people get to do that kind of thing all in a day. Oh, and I cut off a skin tag. So I was like, that's fun. I get to stab people. Well, honestly, I just want to, sorry, I know like we have an episode to get to, but we're still also like just coming back to the season and catching up with each other.

Like think back to when you opened the like first month of Breastfeeding for Busy Moms like over in the Seneca Center. And honestly, like, how much you were like, kind of already hating it because you were like, I hate this building, I hate this office, like, you know, I don't have any clients. Like, look, look at you now.

I think the overall vibe was, I hope people come. Yeah. No, and you were like, so unsure of yourself and like, excited and nervous. And also, I don't know, like, the vibe was so different. Yeah, we've been in this office. It's almost, I mean, it'll, we're in our, well into our second year. Yeah. So we're like unpacked now.

Now we're getting good at it. We're digging our heels in. Yeah. It's kind of, it's incredible. Thank you. I want to start doing a few more procedures if we can. I want to do some uterine ablations and colposcopies and stuff. And if I can, if I can, and you know I will someday, we'll get an ultrasound machine too.

So we can just keep it all in house as much as possible. So nice. That'd be great. Honestly, I've been looking at getting a butterfly. Oh, I know. Those things are fun. They are. So maybe if you decide to get one, we can order them together and save money or something. Well, I can't do the butterfly because they won't do they won't verify it for breast cancer stuff at all.

So like, you can verify whether it's a cyst or not, but then you'd have to send them for another follow up ultrasound and mammogram and stuff. Well, let me know if you make headway there. Maybe we can do something together. Okay, sounds great. Do we have a question today? We do! I think we have a question from our Patreon.

Oh, let me check. Hold on, that's my job. That is your job. I'll thank our patrons while you're looking it up though. Because we do have lots of patrons to thank. So big thank you to our new patrons from over the summer, who, sorry, like, I've neglected all of it over the summer. We did take a real break.

Thank you to Unadeli, Camilla Braun, Nora Wittmayer. Emily Yamaroni, Jennifer Raines, and Laura Reed. Thank you so much for our support. I mean, y'all make this podcast happen. We would not be here, truly, if it wasn't for you. Every single dollar that you guys donate through Patreon goes directly towards producing the show.

So, like, this is not a profitable podcast. People email me all the time asking how much money they could make if they started a podcast. You know, a lot of people ask me, too, and I'm like, I don't know. We haven't figured that part out yet. None. And let me tell you why. So Liquid IV, I'm gonna call them out.

They emailed us and they were like, Oh, hey, by the way, we had to change your code, your promo code, because it got leaked onto the internet, onto a coupon code site. And I was like, isn't that what you want? Like people, and they're like, yeah, but you know, you're, they're not getting it from your podcast.

They're getting it from this like coupon site. And I was like, that's a you problem. And I said, I'm not going back and changing 200 podcast episodes with your commercial in them. So I hope you're comfortable having a code that doesn't work out there. And they did change it back because I threw it. And they're not the only company to do stuff like, I mean, our advert, getting money from advertising, which is how a lot of podcasts really do make money is stupid.

We hate, we hate it. It's so awful. We would so much rather. Like, you guys get something out of it and, and, you know, we are supported by our listeners. I mean, we're still going to do the commercials, but I'm just saying, but, but just please don't go start a podcast thinking you're going to be a millionaire.

We are literally doing this because What we do. We like to get promo codes for you guys so you can get some. It's nice. It's nice for everyone. All right. All right. What's the question for the day? Okay, the question is from a patron Lauren Vandalist. Lauren says hey, can you remind me how many I use of vitamin D3 I should be taking to properly supplement my breastfed baby?

And yes, we actually do have an episode on that that we'll link in the show notes It's episode 31 that we did on vitamin D and breastfeeding feeding, but correct me if I'm wrong, Maureen, but it's about 6, 400 IUs that you're supposed to take per day for enough of it to get through your breast milk.

If you have adequate vitamin D levels. Right. Most of us don't. Although lately with the population I've been seeing whenever we draw labs, it's been better than it used to be. It has been better. My own vitamin D levels have gotten better because I finally got a supplement that also had vitamin D. The, like, correct vitamin K pairing or whatever that helps you absorb the vitamin I don't know.

I don't know about it. Anyway, but I finally am not at, like, 19 anymore. I think I think I got up to, like, 29. I don't know what I am. Still low. It's fine though. You need to be above 30, bud. Yeah. Hey, hey, that's good. I'm getting there. I'm getting there, okay? Well, that's, you know, I can't cast stones because I don't actually know mine.

You want me to take your blood today? Can I dry your blood? Sure. Yes. Oh, these are the best kind of best friends, guys. Get a best friend who will let you take their blood and cut cysts out of your head. Anyway, let's take a quick break, and then we're actually going to talk about Dom Peridone. Yeah, we promise this time.

Alrighty, welcome back. We are ready to get down to business. Okay, today we're talking about Dom Peridone. Do you know what that is? We'll tell you. So, okay, this is Typically, the preferred medication to support milk supply, but it's off label, okay? This is not, like, the intended purpose for this medication.

And we get questions about it absolutely nonstop, especially Heather, because she's a prescriber. How many times do people ask about this? Yeah, a lot. They're like, can you just write me a prescription for Domperidone? And I'm like, I wish. I wish. And you know, actually, there is a statistic out there. That I can't locate at this moment, but it's a ridiculously high percentage of medications that we prescribe.

Every year is off label. So like, it is a very common thing to prescribe a medication off label for something that's not FDA approved, and typically it's fine. The question is whether or not insurance will pay for it. But not so much with Domperidone. Domperidone is like a hard no and everyone's a little bit confused as to why.

And so I'm, I'm excited to learn more today about that because, you know, for example, I've prescribed Viagra for some breastfeeding moms that have had like repeat vasospasms that have a bad reaction to Procardia. And all I have to do is call the insurance company, see if they'll pay for it. Sometimes they say no.

And then I go, Hey, let's look at good RX. And then it's like 20 bucks a month or whatever for them to buy it out of pocket. And it's not a big deal. But with Dom Peridone, I can't find anyone that'll compound it. They won't make it. Can't get it. Yeah. So I just Googled it for you. NCBI says up to a third of all prescriptions.

Yeah. Label usage. That's a lot. A third of all prescriptions are prescribed off label. Are you kidding me? Give me the Dom Peridone. Well, The problem with Domperidone is it is not approved at all for any use in the U. S. by the FDA. So that's the number one qualifier is it has to be approved for something.

And sometimes providers have been able to get it here, but not through any normal channel, okay? I've tried, I've tried. Yeah sometimes it's available through compounding pharmacies, via the internet, but I don't know. It's a little sketchy, to be honest. And the reason the FDA has Refused to approve this.

I don't think it's ever been approved by the FDA. Is because of the risk of cardiac side effects. Which we can get into a little bit more later. However, like, there are definitely riskier drugs approved by the FDA. So Well, so my grandma, here's a little story. story for you. My grandma was in a nursing home and she threw up constantly to the point where she could not keep her medications down.

And Dom Peridone was the only thing that worked to stop her nausea and vomiting. However, because it's not FDA approved in the United States, the nurses at the nursing home Could not give her this medication. So my aunt had to get it from Canada, from a physician in Canada. And she had to drive to the nursing home every day and give her this pill just so she could stop vomiting.

For years, you guys. It's crazy. Well, let's talk about this drug, okay? Because I'm sure a lot of people are like, wait, vomiting? I thought it was for breastfeeding. It's not for breastfeeding. It can be. So, this is actually kind of a new drug. I was like, let me look into the history a little bit. It was only invented, discovered in 1974.

Really? Yeah, and approved for use, like introduced for medical use in 1979. Okay. By Janssen, Janssen Pharmaceuticals. I'm sure you say it with not an American pronunciation. And Domperidone is what we call a peripheral dopamine antagonist. Okay? Not the only peripheral dopamine antagonist in the world, just one of several.

And basically these medications keep dopamine from activating certain types of cells in your brain and in your body. And blocking the dopamine slows down activities that those cells control. So mainly we use dopamine antagonists to treat mental health conditions that involve like excess brain activity.

These are the antipsychotic meds. Okay. However, some of the dopamine antagonists like domperidone have very limited like central nervous system activity. Domperidone does not cross the blood brain barrier and it's, it's a peripheral actor and so we use it as an anti-emetic. Which is just, I don't know, like, sometimes I read these descriptions and I'm like, who figured that out?

Yeah, anti-medic means anti nausea vomiting. And, and just a review of science for y'all, okay? If we have something like an antagonist, right, it'll fit into the receptor, the hole, like the keyhole, for dopamine. Dopamine is the key. And it blocks dopamine from going in there, okay? So it's like if you put the wrong key in your front door, You can't open it until you take it out and put the right key in.

Mm hmm. Okay? So it's like temporarily leaving the wrong key in for, you know, long periods of time so that nobody can open it. That makes sense. Instead of just locking it. And it's just a coincidence that the receptors for nausea and vomiting are similar to the receptors in the brain for mental health stuff?

Apparently. I couldn't find a better explanation. Or is this another case where the brain and the gut are connected? Maybe. But yeah, so Domperidone specifically increases certain movements in the stomach and bowel and decreases others, so basically it causes the top of your stomach to contract and close up.

And the bottom to relax. Nice. So you stop barfing, but you can still poop. So you stop barfing, but you can still poop. That sounds like best case scenario. Yeah, and it's mostly used for palliative care. Right, for managing side effects from 8 million medications, right? Because so many medications to treat serious health problems cause you to vomit.

And this is similar to Reglan. Yes. Except Reglan does cross the blood brain barrier. And the blood brain barrier is that if you can just imagine like a little Sheath over the brain that protects the brain from all kinds of drugs, basically. It's hard to treat the brain because not a lot of drugs can get through this barrier.

Some do, and Reglan is one of those that does. So we end up with more brain side effects like depression and anxiety. Yeah. Which we don't love in postpartum. So anyway, that's why everyone's like, well, yeah, Domperidone is the answer because it's similar to Reglan. It can increase your milk supply, but it does not cross the blood brain barrier.

So what gives? Yeah. Well, let's, before we get into like how and why it works a little bit, let's just talk about some usage and dosage and stuff like that and get those numbers out of the way. Okay. So because this is off label use to use Domperidone for lactation. We don't have, like, good established dosages, but we do have studies on it, okay?

And most studies say that using basically the lowest effective dosage is best, which is 10 milligrams three times daily. We know from infant risk, it tells us that that doesn't produce, like, significant side effects for infants, which is awesome, but it does produce significant increases in serum prolactin.

Which comes from the brain. Right, so cool. And many of the studies we've done also tell us that trying a higher dose doesn't really work. But like if you don't respond to the lower dose, then it doesn't, then you don't need to keep up dosing. It's just not the med for you. I feel like we're learning that about a lot of medications.

A lot of things. So many things that we just don't need to do more, we need to do different. Mm hmm. Yeah. But here's the kicker, and here's why the FDA doesn't want to approve it. It's that dosage is greater than 30 milligrams a day, which is that low dose of 10 milligrams three times a day. cause an increased risk of arrhythmias, sudden cardiac death, all kinds of interesting cardiac issues.

So we have a lot of contraindications. Yeah, but how often does that happen? Right, right. I, yeah, I, yeah, I'm with you. But we should not be taking this med if you have conditions that could cause a bowel blockage like Crohn's or diverticulitis. We should not be taking this. If you have a history of bleeding in the GI tract, if you have a pituitary tumor, if you have liver, kidney, or heart disease.

So that does knock out a lot of people. Actually, that's a lot of people. But let's, let's talk about that a little bit and talk about does it work, why it works, should we be prescribing this to anybody? Yeah. Okay. The FDA makes it sound like we shouldn't be. Well, yeah. The FDA makes it sound like it's imminent that you're going to have a cardiac death if you are trying to boost your milk supply with Domperidone.

And I've read a lot. I've read a lot about this online, and like, the rebuttal is like, the stats are so low on that, and the research is poor. And also that we are using this in incredibly low dosages, you know? For, and we're not using them for long periods of time. No, no. Yeah, this is a short term medication.

So, this works sometimes, and I will have to say that so many times, it works sometimes to increase milk supply because domperidone increases serum prolactin. And I was curious why so I looked it up, right? So prolactin refresher is the hormone that stimulates our cells in our breasts to make milk.

So domperidone increases the prolactin indirectly. by interfering with the dopamine action. Like we said, it's a dopamine antagonist, because one of the actions of dopamine is that it decreases secretions from the pituitary gland. What? I didn't know that. I had no idea. So, wait, say that again. Yeah, so dopamine decreases some of the secretions from the pituitary gland, including prolactin.

Okay, so anyway, so that all boils down to the fact that domperidone causes a higher level of prolactin in your bloodstream. But, and we know this because some old people that took it for nausea and vomiting started lactating at the nursing home. Right, exactly. I really need to know if my grandma was lactating at the nursing home.

No one will tell me. But here's the thing that we have to remember about lactation. All cases of low milk supply are not caused by low prolactin. Right. In fact, probably most of them are not. Right. And high prolactin does not automatically mean a good milk supply. It's just one piece of a larger puzzle.

And also not everyone would be a great candidate for this treatment modality. So I would say, I'm going to ballpark it, but maybe 10 clients a year that I see, I would be like, you're a good candidate. And here's the thing too, that's a little bit tricky about prolactin. When we actually see that sudden, smaller increases of prolactin.

Like we get from nipple stimulation, cause better milk production than just generally having a high level. So like, Domperidone is causing a higher sustained level rather than small peaks throughout the day. And so I don't even, you know, we don't even have great evidence at that then. That causes too much of an increase in lactation.

But regardless, Domperidone is currently considered the preferred prescription galactagogue in many countries, both for increasing milk supply and for inducing lactation. Yeah, and the fact that it's approved in other countries means that we have a lot of data and people aren't just dropping from cardiac arrest all over the world.

And if they were, they'd probably take it off the market. And to be honest, it's approved in some countries that appear to have more stringent Yes. Criteria for approving medications. Somebody pissed in the wrong person's cornflakes I wonder if the FDA just has an issue with that company, because it's not the only, like, I'm like.

With Janssen? Janssen. Yeah, maybe but because we've been using it for this, we do have studies on this. We have several different meta analyses for this drug regarding How it's used to increase milk supply but most specifically the studies are on parents breastfeeding preterm infants. I don't know why.

And, you know, this meta-analysis, a couple of them actually concluded that Domperidone can increase milk supply acutely. So short term, you know, in the range of 90 to 94 milliliters daily, which is pretty significant, especially for preterm infants. Oh, yeah. But some other reviews concluded that simply improving the efficacy of milk removal.

And general breastfeeding practices was safer and just as effective. Well, I guess I'll never know, because they won't give me access. Yeah some of the studies showed that more than a third of the participants experienced no differences when taking the Dome Paradigm. Also, read a meta-analysis that said we basically just don't have enough evidence one way or another to come to any conclusion about people feeding term infants.

Right, because most of the studies are in preterm infants. Well, and there's a lot of confounding variables. It's probably a lot easier to control the environment in a preterm infant, especially if they're inpatient in the NICU. Yeah, and I'm going to get back to that in a second here. Yeah, but also, like, isn't it harder to get a drug trial approved when milk is going into a baby that's premature?

I don't know. And this is where I wanted to talk a little bit about Reglan, too. Okay, Reglan is meadow. Clopramide? Right? Did I say that weird? Metoclopramide. Metoclopramide. Mm hmm. You got this. Because that is essentially the dopamine antagonist that we use in the United States off label to increase milk supply.

So it's the alternative that we have available to us. Mm hmm. And we also have studies for that drug regarding its use in lactation. So I was like, well why don't I read those while I'm reading all these other ones? So, I read this one meta-analysis that included 8 different trials involving a total of 342 lactating folks that used Reglan, and the, the analysis revealed that basically it didn't increase milk volume in the intervention groups compared to the control groups.

And, that there was a significant increase in serum prolactin, but that we just didn't see enough of an increase in actual milk output to say that it worked. Which is, so, so, right, so I, I'm looking at that, I'm looking at all these studies, and we're back to the same problem we always have when we are trying to study milk volume, milk production, milk output.

But, is that there are too many variables to control. Or ones that I read and I'm like, did we control for this at all? Are these people even using the same pump? Did they even have their flanges sized? Like, you know, because that most of these studies are with people who are pumping, right? Cause we have a harder time measuring milk output when we're not pumping and they're not going to have somebody come in for a weighed feed every single day.

And we all, like a lot of the studies didn't even mention, like, did they even counsel? Those breastfeeding parents the same way? Like, did they try to optimize feeding any other way? How many of them were also seeing LCs? Like, Yeah. You know, so much of that wasn't even mentioned. How many of them got a good start to breastfeeding, but had IGT, like didn't have the glandular tissue to support it.

So it's so frustrating and we just always come back to this like once every other week in the podcast, right? We're like, Oh, all these studies suck. Well, I can tell you from my personal experience as a prescriber, and I've prescribed Reglan for, I don't know, probably 20 people, I would say, over the past few years.

I would say a third of them did see an increase, but no more than three to four ounces total in a 24 hour period. So, I would say consistent with that 90 ml per day situation. But, Those were all people, like, I won't prescribe it in someone I don't think will come back to see me. Oh, absolutely. I don't prescribe it in someone who's at risk for anxiety and depression, who's already, like, the other day, perfect candidate, I had someone who was making 15 ounces a day already, and baby was getting close to the six month mark, but not quite there.

So we were like four and a half, almost five months old. Right. And she was like, I just want to try to minimize the amount of formula. She saw a therapist regularly. She was controlled with SSRIs that she'd been on for years. And she was coming back to me consistently. And I said, yeah, I'll try some Reglan with you and we'll see how it goes.

And she maintained her schedule and the baby maintained their weight. And she told me, No, I'm not having any anxiety. I've been working with my therapist on making sure that my level stayed right. And she did. She got up to like, I don't know, 19 ounces a day. Okay. And then baby started eating solids and 19 ounces a day turns out to be just fine when you're eating a bunch of solids.

So she was able to boost to that level and then get there. Was she able to maintain? Yeah. Oh, nice. Yeah. And that's definitely the thing that, you know, we question a lot with these short term galactagogues that we're using where, you know, like, are we able to make enough changes, whole scale, that we can then maintain that milk production after we take this medication out of the picture?

Well, I do a two week trial. Yeah. And, you know, I say, listen, let's, we're going to give it our all, we'll do a two week trial of Reglan. If you're going to take this drug that has that significant side effect possibility of increased anxiety and depression, then I need you to give it your all, like really commit to doing the power pumping and like the skin to skin and all the stuff to boost your supply.

And if it doesn't do anything, we stop it. If it does something, let's do another two weeks of it and then we'll reevaluate. But like I check in every two weeks. Yeah, and, and that brings me to side effects because the reason Domperidone is reportedly better than Reglan basically is because it has less side effects and that at a low dose most people are very tolerant of that medication, which is honestly not that different from Reglan though.

But hey, it has a lot of possible side effects and some are kind of scary, you know. The, the not so scary ones are like dry mouth and headache and dizziness and abdominal cramping and diarrhea, you know, like every single. Drug advertisement says at the end. The big one though is that there's an association between abrupt discontinuation of domperidone used for lactation stimulation and the development of psychiatric adverse events.

So like the Canadian labeling warns against the use of domperidone. in doses greater than 30 milligrams a day and longer than four weeks. And if you are taking it long term, you have to taper off extremely slowly to avoid a psychiatric event. And a lot of people have some pretty intense withdrawal symptoms when they come off of it.

I mean, I have not seen that be the case with Reglan. Like, we taper off of Reglan, but I don't taper them for more than a week or two. Yeah, but you're also not doing very long term Yeah. Use. You know? Yeah. So that's the thing. Like, it's really balancing the shortest term of use that we can with effective interventions.

You know, it's, it's complicated. And there's, and because it's off label, there's no protocol. There's no real protocol. There's like some suggested protocols that are like, Hey, this has been working for me. Yeah. For most people in my practice, but it's not, it's not like, Hey, we did this huge study and like, this is what we found to be the best way to, you know, scale up on the drug and also taper off and maintain all that.

So, yeah, I mean, we barely have the studies to even prove effectiveness at all, much less anything else. But that does bring me to safety for baby, you know, I mentioned briefly it was considered pretty safe. I have a question. If Domperidone doesn't cross the blood brain barrier, then why does it have such significant side effects mentally when you taper off?

Got nothing. That's just what Canada says. Wow, that's weird. I don't know but for safety for baby We did have a couple of small studies on the excretion of domperidone into breast milk pretty inconsistent results, but mostly we had Results saying that the infants would receive less than zero point one percent of the maternal adjusted dosage even at higher doses so Really not, not very many cases at all of any adverse effects for the infants, which was really great.

But infant risk is like, hey, make sure your kid's not getting diarrhea, you know? Okay, but like every parent out there is like does my baby have diarrhea or is it just loose because it's baby poop? Yeah, with diarrhea, we're always looking at a differential diagnosis, you know, for infants because all their poop is kind of liquidy.

But you just have to get really familiar with signs of dehydration. Basically. You know, cause they can have really liquidy poops and be totally fine. Yep. The half-life of this drug is kinda longer, it's 7 14 hours, and the oral bioavailability is low. It is 13 17%. Very interesting. Alright, well, speaking of Digesting and bioavailable things.

I need a minute to digest this information. Let's take a quick break and when we get back, I want to tell you what my experience has been like trying to get this drug in the United States. I would love to hear that.

Welcome back everybody. All right, so here's the thing. This is my experience. I have gone. Many, many different directions trying to get Dom Peridone to try it, because I'm comfortable trying it. I'm already prescribing Reglan occasionally for milk supply, and I know what I feel comfortable with as far as management.

So I feel comfortable using Dom Peridone, probably more comfortable using it than Reglan. I just can't get it. So I have, I have ordered it from a, an Island somewhere in the world. It took a month to get here. It had to get through customs. It was, which is so sketchy, you know? And like, meanwhile this mom is trying to boost her supply and it's like a month goes by.

You could be in a writing on this one medication that's not here yet. That's not working. Like we can, so obviously I went through all like cost benefit with her and she was like, let's do it. But it was a pain in the ass and like they had to. Call her and email her and they had to get her information and her husband was like, what's this crazy midwife got you doing?

And it just was not normal. It didn't feel good. I have also tried to refer patients to the Jack Newman place in Canada and the problem with that was the referral process was really clunky. I think that they're probably, I'm guessing, really busy just with their, with their current patients that are in Canada.

And like, I get it, like your country has to prioritize your people. But they do, I thought, advertise for like, yeah, we'll be your Canadian doctor and then we'll prescribe it in Canada and then we'll mail it to you. Yeah. And I think, like, the ball was just totally dropped after, I mean, Abigail, my best friend and office person, was filling out multiple different referral forms and emailing and calling, trying to get this patient scheduled, and it was going to have to be out of pocket, because obviously in Canada they don't take the insurance, so it was just not a great time.

Thorough experience and did not result in Dom Peridone. Mm hmm. I have also gone the sketchiest route where you have somebody who has brought over a giant bottle of it from India or from somewhere in Europe and they're like, I have some at my house. It's like a doula who's like, Yeah, I've got some Dom Peridone.

Do you want some? And it's like, I mean Yes. Yeah, but also no . I just, I just want to feel good about the care that I'm giving, and it's not that I don't trust that the pills that came in that giant carry on bottle from India are good . It's just that, you know, it doesn't feel good. Yeah, it just doesn't feel good.

It feels wrong. So. I have also called multiple compounding pharmacies in the United States asking if I could prescribe the different components of it and see if maybe they could put it together. They all said no. I have tried ordering it through Medications Canada myself, but because I have a midwifery license as a CNM, they, they know why I want it.

And therefore they will not allow me to use it. I have even lied and I've put on the prescription, no, it's for GI stuff. And they're like, nope, you can't have it. And I'm like, damn it. So, yeah, I've really given it a solid effort, but I have not been successful. And I guess there's been like a recent in the past couple years regulation change with compounding pharmacies where they're required to purchase this 15, 000 plus dollar machine.

that makes it okay to compound. And so a lot of the smaller compounding pharmacies were like, fuck it. Like we were not doing this anymore. And insurance like really doesn't enjoy paying for the compounds or won't like just flat out won't pay for them. So it's all out of pocket anyway. So it's just like barrier after barrier.

So I think I'm like done trying to get it to be honest. Yeah. I mean, I get it. It's not, It's not worth the very small possible benefits, especially when we do have an alternative medication that is easy to prescribe. Right, and most of the time, just in my experience, it's only been a couple of weeks that we're really trying this, and we're trying a million other things too.

And not everybody's a great candidate. So it's not something that's like, My whole practice is riding on. Yeah. Like most people's milk supply is not riding on this golden ticket. Like I feel like a lot of people have sort of heard about it as this like magical milk supply thing and it is really great when it works, but it's just not gonna fix every case of low milk supply.

Sadly, no. We, I mean, in America, the way we think about things is we, we have a problem. We take a pill for that problem. Yeah. And lactation just refuses to fit in that Americanized box way of thinking. It just, it fits in every box. It's every woman's box. And it just, we can't make it go away like that. So. I don't know.

I guess the overall message here is like, go to a practitioner who you think can look at your milk supply issue from a multifaceted perspective and give you all of the options and then really weigh the cost and the benefit and, you know, all of that for performing those interventions, because anything that's going to boost your milk supply, is work.

It's effort, it's time, and it's emotional, and you should not have to go through that on your own. And so, like, I'm glad that there's not just, like, a pill out there for people to take, because I don't think that people should be at home just, like, popping pills, crying, trying to boost their supply, when maybe you don't even really have a problem.

Or maybe your problem is actually something totally different that really needs to be addressed from a medical standpoint in another way. So I kind of feel like the first step is always going to be to do a thorough evaluation. And then, you know, if you think that you'd be a good candidate for Reglan, absolutely bring it up.

Yeah. And if you have a practitioner who's worth their salt, they're going to review all of the risks, benefits, and alternatives with you. Alright, well, I think we should conclude here with a little award, maybe read some happy stuff. Happy stuff. Well the award in the alcove today goes to Ashley H. from our Facebook group.

She posted this really cute little picture and said she felt pretty for the first time in a long time sitting 18 month old. Oh, that's awesome. And I feel like that's a huge win. Like Way to get your spark back, you know? Oh the sparkle we're always trying to chase the sparkle, aren't we? Absolutely No, and I know that feeling when you just kind of look at yourself and you're like, oh, it's me Oh, hey there.

I'm back. So Congratulations for getting there because we know that's not easy to do. I'm going to give you the beach bum award. Oh good one and just say like, you know way to go keep going as long as you want to absolutely Alright, and before we let you go, I would like to read a very sweet email that we got from Anne Marie Hext.

She says, Heather and Maureen, I just listened to your season finale episode. Great topic and so relatable. I was belly laughing right along with you in my car. If there was something more emphatic than Caps Lock, I would use it to say THANK YOU BOTH, in all caps, for all the time, passion, and raw honesty you pour into the Milk Minute podcast.

I've learned so much from you both. Understatement. And you keep me fresh and current with today's parents. Thank you for finding a production schedule that will allow you two to continue to kick asses, midwives, lactation professionals, and small business badasses while preserving this podcast. I am ever so grateful.

Enjoy the off season and take a moment to celebrate your awesomeness. Best, Annemarie. That was so sweet. I freaking needed that because I was feeling super guilty about taking time off. Absolutely. Like, really guilty. Like, when you do something for four years, it's like almost a lifestyle at that point.

And taking a break from it is weird and so necessary. We really did need it. So I appreciate all the love and support that you guys have given us and I love that you're able to see the bigger picture, that we're going to be able to do more episodes and keep it going if we do pace ourselves and take breaks.

So much appreciated. Yeah, well thank you guys for listening to another episode of the Milk Minute. The way we change this big system that is not set up for lactating parents or people that have nausea and vomiting and would like to stop having that is by educating ourselves, our friends, our loved ones, and maybe even the FDA.

And if you liked this episode or any other, please share it with a friend, tell a friend about our podcast, or consider becoming a patron at Patreon. com slash MilkMinutePodcast. And you could leave us a review on Apple if you like, that'd be really nice. Yeah, we like those too. Alright, you guys have a good day, we will see you next week.

Bye bye!