Domperidone

Herzl Family Practice Centre, Goldfarb Breastfeeding Clinic Patient handout

What is domperidone?

• Domperidone is a pill that can increase breastmilk by increasing your levels of prolactin (the hormone responsible for milk production).
• This pill was originally developed for stomach problems such as reflux and nausea. However, it is now being used widely in breastfeeding mothers.

Who needs it?

1. Domperidone is not for everyone. There are specific reasons for this medication.
2. If you feel you do not have enough milk, you should first see a lactation consultant and/or doctor.
3. It is important to try other ways of increasing milk supply first (without pills).
4. Other medical problems may need to be treated first. Blood tests may need to be done.

Is domperidone safe?

• Domperidone is the only breastmilk-increasing medication studied and shown to be safe and effective.
• It has been used safely for many years in many developed countries including Canada, Australia and European countries.

Domperidone is also approved by Health Canada for use in children and adults for stomach problems. In fact, the dose received by the infant through breastmilk is far less than the dose given to children.

What to be careful about when taking domperidone:

Domperidone, like all medicine, may have side effects and risks. However, we believe that breastfeeding while on domperidone is a safer alternative than having to give formula.

If you have had any of the following conditions, you should discuss this with a doctor before starting domperidone:

• History of bowel or colon surgery.
• Gastrointestinal conditions causing problems with digestion or absorption.
• Heart conditions causing chest pain, shortness of breath, palpitations, fainting or dizzy spells or if you have been diagnosed with having long QT waves.
• A family history of heart problems, unexplained fainting or sudden death.
• History of heart surgery.
• A brain tumor (prolactinoma) causing increased prolactin.

Domperidone can interact with other medication. It is important that you tell your doctor or pharmacy you are taking domperidone before you are given any medication.

Medications that may interact with domperidone:

• Cisapride (Propulsid™)
• Medications used to treat fungal infections or thrush, i.e. fluconazole (Diflucan™)
• Some antibiotics, i.e. ciprofloxacin (Cipro™), levofloxacin (Levaquin™), erythromycin, and azythromycine (Zithromax™).
• Grapefruit and its juice (and possibly grapefruit seed extract).
• Some antidepressants, i.e. amitriptyline (Elavil™), fluoxetine (Prozac™), and paroxetine (Paxil™).
• Lithium.
• Some HIV medication.

How to take domperidone:

• Usually, you will be asked to start domperidone at a dose of 10 mg (or 1 pill) 4 times a day. The maximum dose is 30 mg (3 pills) 4 times a day.
• You may feel an increase in milk production anywhere from 2 -3 days to 2-3 weeks after starting domperidone.
• Domperidone is a long-term medication. You have to take it continuously for at least 3 to 8 weeks for it to have its full effect. Most mothers take it for a few months, and stop gradually after discussion with their health professional.
• It is important to continue pumping and putting the baby to the breast as often as possible while on domperidone. Domperidone does not act alone. It is helped by breast stimulation. If the breasts are not stimulated, domperidone will not be able to do its job as well.
• You may continue taking herbs along with domperidone, if you feel that the herbs are helping as well.

Side effects:

Side effects are not very common, and usually improve after a week of taking domperidone.

The main side effects are:

• Headache
• Dry mouth
• Dizziness
• Diarrhea (or change in bowel movements), abdominal cramps
• Increased appetite
• Weight gain
• Fatigue

The information contained in this patient handout is a suggestion only, and is not a substitute for consultation with a health professional or lactation specialist. This handout is the property of the author(s) and the Goldfarb Breastfeeding Clinic. No part of this handout can be changed or modified without permission from the author and the Goldfarb Breastfeeding Clinic. This handout may be copied and distributed without further permission on the condition that it is not used in any context in which the International Code for the Marketing of Breastmilk Substitutes is violated. For more information, please contact the Goldfarb Breastfeeding Clinic, Herzl Family Practice Centre, SMBD Jewish General Hospital, Montreal, Quebec, Canada. © 2009

Decreased milk production

Herzl Family Practice Centre, Goldfarb Breastfeeding Clinic Patient handout

There are many medical and non-medical ways of increasing milk production. It is never “too late” to increase milk production if you are willing to seek help and put in some effort.

How can I tell if I don’t have enough milk?

Decreased milk production means that your baby needs more milk than you can produce.

Signs that your baby is getting enough milk:

• There is one wet diaper for each day of life until day 6 → then 6 or more heavy wet diapers in 24 hours.
• Stools are soft and yellow from day 5 of life onwards (only if exclusively breastfeeding).
• Baby is alert, wakes up on his/her own to feed, and is satisfied after feeds.
• Baby is back to birth weight by day 10-14 of life, after possibly losing 7-10% of its initial weight.
• Baby gains 20 to 30 g/day during the first 3-4 months of life, then 15-20 g/day after that.
• Your breasts are fuller before feeds, and softer after feeds.

These signs are not written in stone, and it is important to follow-up regularly with your health care provider to ensure that your infant is growing and developing well.

Important: the amount of breastmilk that you are able to pump does not always show how much milk you truly have. Your baby will almost always be able to get more milk out of your breasts than a breast pump will be able pump out.

How to increase breastmilk production without pills:

• First of all, make sure your baby has a good latch and that you have no pain while nursing. A good latch will help your baby get more milk, and will also better stimulate the breasts to produce milk.
• Breastfeed often (8-14 times in 24 hrs) and try to drain the breasts at every feed, so that they feel soft afterwards.
• Place the infant directly skin-to-skin to help increase milk supply, during and in between feeds.
• Pump or manually express your milk after feeds to increase milk production by stimulating your breasts more. Even as little as 5 minutes of pumping after feeds can make a big difference. If the baby is not at the breast at every feed, then you may need to pump for longer, and more often. For babies who are not at the breast at all, you will need to pump at least 6 times in 24 hours or as many times as the baby feeds to keep up your milk supply.
• You may be shown how to do “breast compressions”, which are 5-second squeezes of the breast while your baby is feeding, to encourage milk flow.
• Switch nursing is another term you might hear about. This means switching the baby from one breast to the other rapidly (perhaps after a few minutes) so as to stimulate your let-down reflex. You may end up feeding in the following way: right breast for 5 min, then left breast for 5 min, then right breast again for 5 min, then left breast again for 5 min, etc.

Supplementation:

What if I need to supplement?

If you need to supplement for any reason, remember that this does not mean that you have failed at breastfeeding, and it may only be temporary.

The best way to supplement is by using your own pumped milk. If that is not available, donor milk is the second best option. The third option for supplemention is infant formula. It is best to avoid powdered formula as it is not sterile.

There are many ways to supplement your baby, including:

• Using a lactation device or tubing at the breast.
• Cup-feeding.
• Finger-feeding with a tube.
• Bottle-feeding.
• Dropper or syringe-feeding.

Avoiding the use of a bottle may help in making sure your baby latches well onto the breast. Please speak to a lactation professional to see which of these methods is right for you.

How to store breastmilk:

Breastmilk is very valuable, so it is important to store every drop for later use. For healthy term infants, freshly expressed breastmilk can be stored in the following ways (Academy of Breastfeeding Medicine Guidelines):

• At room temperature (up to 25°C or 77°F) for 6 to 8 hours.
• In an insulated cooler bag with ice pack for 24 hours.
• In the refrigerator (4°C or 39°F) for up to 5 days.
• In a freezer compartment inside the refrigerator (-15°C or 5°F) for 2 weeks.
• In a freezer located above the refrigerator (-18°C or 0°F) for 3 to 6 months.
• In a chest or upright freezer (-20°C or -4°F) for 12 months.

The information contained in this patient handout is a suggestion only, and is not a substitute for consultation with a health professional or lactation specialist. This handout is the property of the author(s) and the Goldfarb Breastfeeding Clinic. No part of this handout can be changed or modified without permission from the author and the Goldfarb Breastfeeding Clinic. This handout may be copied and distributed without further permission on the condition that it is not used in any context in which the International Code for the Marketing of Breastmilk Substitutes is violated. For more information, please contact the Goldfarb Breastfeeding Clinic, Herzl Family Practice Centre, SMBD Jewish General Hospital, Montreal, Quebec, Canada. © 2009

Candida or thrush of the nipple and breast

Herzl Family Practice Centre, Goldfarb Breastfeeding Clinic Patient handout

Definition:

Candida albicans is a type of fungus that can cause infections in various warm and humid places, such as the nipples, breasts, skin, vagina, mouth, and baby’s bum → these infections are commonly called “thrush” or “yeast infections”.

Risk factors for developing thrush:

For mother:

• Recent use of certain medications like: antibiotics, birth control pills, or anything with cortisone or steroids.
• Cracked or damaged nipples.
• Vaginal infections.
• Diabetes.
• A weak immune system.
• Diet → very high in sugar and yeast, or low in vitamins and minerals.

For baby:

• Use of a bottle nipple or pacifier.
• Use of artificial infant formula.

If you have thrush, you may notice the following:

In the mother:

• Redness, shininess, irritation and/or peeling skin on the areola or nipple.

Nipple and/or breast pain:

• Often at the end of a feed, or anytime during or in between feeds.
• Burning and/or itchiness of the areola or nipple.
• Deeper pain, either burning, throbbing, or shooting.
• Pain that does not get better even with a good latch.

In the baby:

• White plaques in the mouth or on the tongue that you cannot remove.
• A red rash on the bum and diaper area.
• A fussiness or refusal to take the breast, or general irritability.

Even if the baby has no signs of infection, the mother may still be infected, and needs to seek treatment from a health professional or lactation specialist.

How to treat a candida infection?

First of all, make sure your baby has a good latch and that you have no pain while nursing.

Home remedy:

It is important to seek professional help if you think you might have thrush. However, you can try this home remedy in the meantime.

Rince your nipples with 1 tablespoon (15 ml) vinegar in 1 cup water (250 ml), every hour for a 24-hour period.

Treatments that may be suggested by your health professional:

The use of Advil™ or Motrin™ (ibuprofen) and/or Tylenol™ (acetaminophen) may be very useful to treat the pain of thrush. These medications are safe during breastfeeding.

Gentian violet, in a 1% aqueous (water-based) solution:

• Use a cotton-tipped Q-tip to apply the solution in the baby’s mouth (swab inside baby`s cheeks, gums, tongue, roof of the mouth and under the tongue) so that all areas are covered violet. Once that is done, let the baby feed on both breasts. Make sure you use a fresh Q-tip with every application.
• Otherwise, you can paint both nipples and areola with a Q-tip of gentian violet, and let the baby feed afterwards. The baby`s inner mouth will also turn violet.
• Note: You do not have to apply Gentian violet in the baby`s mouth AND on your breasts, one of the above is enough.
• Apply once a day, before a feed, for a period of 4 to 7 days. Whether things are better or not, the treatment should be stopped in 7 days, and you should return to see your health professional.
• Gentian violet is safe for breastfeeding mothers and babies. However, in rare cases, it can cause some irritation in baby’s mouth. If you suspect this, stop the treatment immediately and contact your health professional. ** Be careful, as Gentian violet can stain clothes.

Grapefruit seed extract (GSE):

• There are 2 ways of using GSE:
• Mix 2-5 drops of GSE in 30 ml (1 oz) of distilled water. Use a Q-tip to apply this diluted solution on the nipple/areola after every feed. If also using APNO (see below), you can apply it to the nipple/areola after the GSE. Remember to change the Q-tip with every new application.
• GSE can also be taken orally by the mother. The dose is 250 mg 3 times in a day in pill form, or 5 drops in water 3 times a day.
• GSE can be added to the laundry, in a dose of 15-20 drops in the rinse cycle.

Remember that certain medications do not mix with GSE, such as domperidone (used to increase breastmilk supply) and fluconazole (a medication for thrush, discussed below).

Grapefruit seed extract is safe in breastfeeding mothers and babies.

• These treatments can be done together, and can continue for 2-4 weeks or more, depending on instructions from your health professional.
• Probiotics can be useful to treat and prevent thrush. You can take them in the form of Bio-K in yoghurt or pill form, acidophilus pills, or yoghurt pills. You may take probiotics for weeks, based on instructions from your health professional. They are safe for breastfeeding mothers and babies.

APNO (all-purpose nipple ointment):

• APNO is available by prescription only, and is made of 3 ingredients, an anti-fungal, anti-bacterial, and anti-inflammatory.
• A thin later of APNO should be applied on the nipple and areola after every feed.
• Make sure to check with your health professional for long you can use APNO.
• APNO is safe for breastfeeding mother and babies, but if you feel any burning, irritation or pain while using it, stop right away and contact your health professional.

Fluconazole (DiflucanTM):

• This is a pill to treat thrush which is usually reserved for severe, long-standing or repetitive cases of thrush.
• The dose is 400 mg the first day, followed by 100 mg twice a day for 2-4 weeks or longer if instructed by your health professional.
• Fluconazole cannot be taken with grapefruit or grapefruit seed extract, and is safe for breastfeeding mothers and babies.

Home hygiene:

For cases of severe or repetitive thrush, certain things can be done in the home to prevent the growth of fungus in general. Note that these things are not essential if your thrush is easily treated, only if it keeps on coming back, or does not go away easily:

• Wash your hands and baby’s hands often.
• Wash your breasts and nipples in the shower/bath daily with water and soap.
• Wear a fresh clean bra everyday.
• If you are using breast/nursing pads, use disposable ones, and change them after every feed.
• Wash all clothes and towels that come into contact with your breasts or baby in hot water.
• Any object which is put in baby’s mouth can come into contact with candida:
  • Boil pacifiers, bottle nipples, teething rings, baby’s tooth brush, and medication droppers for about 20 minutes, once a day.
  • After a week of treatment for thrush, throw out the above objects and buy new ones.
• If you are using a breast pump, boil all the pieces that come into contact with your milk, for 20 minutes every day.

More home hygiene:

If the above don’t work, and you are still dealing with recurrent thrush, you may want to try the following:

• Start using paper towels to wipe your hands, instead of the same towel.
• For laundry, you can add 1 cup (250 ml) of bleach in the wash cycle, and 1 cup (250 ml) of vinegar in the rince cycle to boost washing power.
• Clothes can be dried in the dryer or on a clothesline exposed to the sun (if possible). Ironing clothes can also kill candida.
• All family members should be checked and treated for any candidal infections.
• Pets can also get candida infections.

Normally, you should feel better with the treatment prescribed by your health professional. If you are not better, it is important that you return to see your health professional.

The information contained in this patient handout is a suggestion only, and is not a substitute for consultation with a health professional or lactation specialist. This handout is the property of the author(s) and the Goldfarb Breastfeeding Clinic. No part of this handout can be changed or modified without permission from the author and the Goldfarb Breastfeeding Clinic. This handout may be copied and distributed without further permission on the condition that it is not used in any context in which the International Code for the Marketing of Breastmilk Substitutes is violated. For more information, please contact the Goldfarb Breastfeeding Clinic, Herzl Family Practice Centre, SMBD Jewish General Hospital, Montreal, Quebec, Canada. © 2009