Postpartum domperidone use in British Columbia: a retrospective cohort study

Longitudinal trends in domperidone dispensing to mothers of very preterm infants and its association with breast milk feeding at infant discharge: a retrospective study

OBJECTIVE

This study aims: (a) to evaluate patterns of domperidone dispensing to mothers of very preterm (<32 weeks gestation) infants born before and after 2014 when international recommendations were made to limit its use and (b) to examine characteristics associated with domperidone dispensing and impacts on breast milk feeding rates at infant hospital discharge.

DESIGN

Retrospective audit using linked electronic medical records and hospital pharmacy records.

SETTING

Tertiary-referral neonatal intensive care unit at the Women's and Children's Hospital in South Australia.

PATIENTS

Mothers of preterm infants admitted to neonatal intensive care from January 2004 to December 2018.

MAIN OUTCOME MEASURES

Rate of domperidone dispensing compared pre-2014 and post-2014 recommendations using interrupted time series analyses, and breast milk feeding rates at infant discharge based on domperidone treatment status, adjusted for other factors known to influence breast milk production.

RESULTS

Overall, domperidone was dispensed to 691 (41%) of 1688 mothers. Prior to 2014 recommendations, the proportion of women dispensed domperidone was stable. Following the recommendations, there was a significant reduction in trend (-2.55% per half year, 95% CI -4.57% to -0.53%;), reflecting less domperidone dispensing.Breast milk feeding rates at discharge remained consistently lower in infants of women dispensed domperidone than those who were not (adjusted OR 0.58, 95% CI 0.45 to 0.75).

CONCLUSION

Domperidone dispensing in mothers of hospitalised very preterm infants has declined over time following international regulatory warnings. Breast milk feeding rates remain lower in mothers prescribed domperidone, suggesting further research is needed to optimise lactation support for mothers of very preterm infants.

Women's experiences with using domperidone as a galactagogue to increase breast milk supply: an australian cross-sectional survey

BACKGROUND

Domperidone is one of the most commonly utilised pharmacological galactagogues, with evidence of increasing use in clinical practice. However, the use of domperidone as a galactagogue remains controversial, with mixed evidence on safety and efficacy, leading to variable clinical practice recommendations. We sought to evaluate contemporary patterns of domperidone use and examine maternal experiences related to perceived safety and effectiveness.

METHODS

In 2019, we conducted an online, cross-sectional survey of Australian breastfeeding women to examine individual experiences related to domperidone use, in addition to perceptions of safety and effectiveness.

RESULTS

Among 1876 survey responses, 19% (n = 355) reported using domperidone. Domperidone use was significantly higher in women who were primiparous, gave birth preterm, delivered by caesarean section, had self-perceived low milk supply, and saw a lactation consultant. Nearly 20% of women commenced domperidone use in the first week postpartum (19%, n = 67). The median duration of use was six weeks (interquartile range 3-16 weeks). Maximum reported doses of domperidone used ranged from 20 mg/day to 160 mg/day. Half (n = 178, 50%) of women reported using a dose of 30 mg/day or less, 44% (n = 155) reported using a dose between 31 and 60 mg/day, and 6% (n = 22) reported using a dose greater than 61 mg/day. Nearly half of the respondents reported domperidone as 'very' or 'extremely effective' (45%, n = 161), with only 8% (n = 27) reporting it was 'not at all effective'. Almost half (n = 172, 48%) of all women using domperidone reported side effects, including weight gain (25%), headaches (17%) and dry mouth (13%). Higher doses were associated with an increased likelihood of any side effects (≤ 30 mg/day, 38%; >31-≤60 mg/day, 48%, > 61 mg/day 73%; P < 0.004), with 31 (9%) stopping domperidone because of side effects.

CONCLUSION

We identified widespread variation in domperidone utilisation patterns, with domperidone broadly perceived to be effective in increasing breast milk supply. Side effects associated with domperidone treatment were common, appeared to be dose-related, and were frequently associated with treatment cessation. These findings highlight the importance of improved clinical practice recommendations and generation of evidence from additional high-quality clinical trials evaluating the efficacy and safety of domperidone. More conclusive clinical trials are needed to determine the efficacy, as well as optimal dose and duration, of domperidone use.

Prevalence of Mental Health Disorders Among Immigrant, Refugee, and Nonimmigrant Children and Youth in British Columbia, Canada

Importance

There remains limited understanding of population-level patterns of mental disorder prevalence for first- and second-generation immigrant and refugee children and youth and how such patterns may vary across mental disorders.

Objective

To examine the diagnostic prevalence of conduct, attention-deficit/hyperactivity disorder (ADHD), and mood/anxiety disorders in immigrant, refugee, and nonimmigrant children and youth in British Columbia, Canada.

Design, Setting, and Participants

This retrospective, population-level cohort study examined linked health administrative records of children and youth in British Columbia (birth to age 19 years) spanning 2 decades (1996-2016). Physician billings, hospitalizations, and drug dispensations were linked to immigration records to estimate time-in-British Columbia-adjusted prevalence of mental disorder diagnosis among children and youth from immigrant or refugee backgrounds compared with those from nonimmigrant backgrounds. Analyses were conducted from August 2020 to November 2021.

Main Outcomes and Measures

The diagnostic prevalence of conduct, ADHD, and mood/anxiety disorders were the main outcomes. Results were stratified by migration category (immigrant, refugee, nonimmigrant), generation status (first- and second-generation), age, and sex.

Results

A total of 470 464 children and youth in British Columbia were included in the study (227 217 [48.3%] female). Nonimmigrant children and youth represented 65.5% of the total study population (307 902 individuals). Among those who migrated, 142 011 (87.8%) were first- or second-generation immigrants, and 19 686 (12.2%) were first- or second-generation refugees. Diagnostic prevalence of mental disorders varied by migration category, generation status, age, and sex. Children and youth from immigrant and refugee backgrounds (both first- and second-generation), compared with nonimmigrant youth, generally had a lower prevalence of conduct disorder (eg, age 6-12 years: first-generation immigrant, 2.72% [95% CI, 2.56%-2.90%] vs nonimmigrant, 7.03% [95% CI, 6.93%-7.13%]), ADHD (eg, age 6-12 years: first-generation immigrant, 4.30% [95% CI, 4.10%-4.51%] vs nonimmigrant, 9.20% [95% CI, 9.08%-9.31%]), and mood/anxiety disorders (eg, age 13-19 years: first-generation immigrant, 11.07% [95% CI, 10.80%-11.36%] vs nonimmigrant, 24.54% [95% CI, 24.34%-24.76%]). Among immigrant children and youth, second-generation children and youth generally showed higher prevalence of conduct, ADHD, and mood/anxiety disorders than first-generation children and youth (eg, ADHD among second-generation immigrants aged 6-12 years, 5.94% [95% CI, 5.75%-6.14%]; among first-generation immigrants aged 6-12 years, 4.30% [95% CI, 4.10%-4.51%]). Second-generation refugee children had the highest diagnostic prevalence estimates for mood/anxiety in the 3-to-5-year age range relative to first- and second-generation immigrant and nonimmigrant children (eg, second-generation refugee, 2.58% [95% CI, 2.27%-2.94%] vs second-generation immigrant, 1.78% [95% CI, 1.67%-1.89%]). Mental disorder diagnoses also varied by age and sex within immigrant, refugee, and nonimmigrant groups.

Conclusions and Relevance

These findings show differences in diagnostic mental disorder prevalence among first- and second-generation immigrant and refugee children and youth relative to nonimmigrant children and youth. Further investigation is required into how cultural differences and barriers in accessing health services may be contributing to these differences.

"Fear of stopping" vs "wanting to get off the medication": exploring women's experiences of using domperidone as a galactagogue - a qualitative study

Background

Domperidone is the most frequently prescribed medicine used to increase breast milk supply. There is considerable controversy surrounding the use of domperidone in lactation, due to limited evidence about efficacy and concerns about rare but life-threatening side-effects. Despite this, in many high-income settings such as Australia, use of domperidone among breastfeeding mothers appears to be increasing. The aim of this paper was to explore women’s experiences of using domperidone during breastfeeding.

Methods

Semi-structured interviews were conducted in 2019 with 15 women in Australia who reported using domperidone as a galactagogue during breastfeeding. Interviews were recorded, transcribed and analysed thematically.

Results

Women reported a wide variety of practices concerning the timing of initiation of domperidone use, including prophylactic use, as well as the dose and duration of use. Prolonged periods of use and unsupervised dosing were commonly reported, these practices were sometimes associated with a fear of the consequences of stopping, insufficient provision of information about the drug or feeling dismissed by health professionals. Some women indicated that when doctors refused to prescribe domperidone they responded by doctor shopping and seeking anecdotal information about benefits and risks online, leading to unsupervised practices. Women often reported high expectations surrounding the effectiveness of domperidone, and most used the medication in conjunction with food/herbal galactagogues and non-galactagogue support. Positive outcomes following domperidone use included having greater confidence in breastfeeding and pride at achieving breastfeeding goals.

Conclusions

This study identified a variety of practices concerning domperidone use, including potentially unsafe practices, linked in some cases to inconsistent advice from health professionals and a reliance on online, anecdotal information sources. These findings emphasise the urgent need for development of clinical practice guidelines and a greater focus on translating existing evidence concerning domperidone into clinical practice, including clinical support that is tailored to women’s needs.

Use and experiences of galactagogues while breastfeeding among Australian women

Background

Galactagogues are substances thought to increase breast milk production, however evidence to support their efficacy and safety remain limited. We undertook a survey among Australian women to examine patterns of use of galactagogues and perceptions regarding their safety and effectiveness.

Methods

An online, cross-sectional survey was distributed between September and December 2019 via national breastfeeding and preterm birth support organisations, and networks of several research institutions in Australia. Women were eligible to participate if they lived in Australia and were currently/previously breastfeeding. The survey included questions about galactagogue use (including duration and timing), side effects and perceived effectiveness (on a scale of 1 [Not at all effective] to 5 [Extremely effective]).

Results

Among 1876 respondents, 1120 (60%) reported using one or more galactagogues. Women were 31.5 ± 4.8 years (mean ± standard deviation) at their most recent birth. Sixty-five percent of women were currently breastfeeding at the time of the survey. The most commonly reported galactagogues included lactation cookies (47%), brewer’s yeast (32%), fenugreek (22%) and domperidone (19%). The mean duration of use for each galactagogue ranged from 2 to 20 weeks. Approximately 1 in 6 women reported commencing galactagogues within the first week postpartum. Most women reported receiving recommendations to use herbal/dietary galactagogues from the internet (38%) or friends (25%), whereas pharmaceutical galactagogues were most commonly prescribed by General Practitioners (72%). The perceived effectiveness varied greatly across galactagogues. Perceived effectiveness was highest for domperidone (mean rating of 3.3 compared with 2.0 to 3.0 among other galactagogues). Over 23% of domperidone users reported experiencing multiple side effects, compared to an average of 3% of women taking herbal galactagogues.

Conclusions

This survey demonstrates that galactagogues use is common in Australia. Further research is needed to generate robust evidence about galactagogues’ efficacy and safety to support evidence-based strategies and improve breastfeeding outcomes.

The risk-risk trade-offs: Understanding factors that influence women's decision to use substances to boost breast milk supply

Galactagogues are foods, herbs or medications thought to support or increase breast milk supply. The use of galactagogues during lactation is becoming increasingly common despite limited evidence regarding effectiveness and safety, and no definitive recommendations for use in clinical practice. The aim of this study is to explore factors influencing women's decisions to use galactagogues during lactation. Twenty-two semi-structured interviews were conducted in October and November 2019 (over the telephone or in person) with participants located in most Australian states and territories, including metro and regional areas. Interviews were audio-recorded, transcribed verbatim and thematically analysed using NVivo. Analysis revealed that following a concern about breast milk supply, the decision to use galactagogues was influenced by three core and interrelated domains: access to and quality of breastfeeding support, maternal agency and determination to provide breast milk. Women revealed many problematic experiences with health care professionals that left them feeling dismissed and confused due to provision of inconsistent and insufficient information that was sometimes at odds with their desire to provide breast milk. In this instance, some women turned to galactagogues to regain agency. A range of broader dimensions influencing decision-making also emerged. These were separated into categories that emphasise distinctions relating to breast milk supply, which included: maternal emotional wellbeing, social norms and pressures, concerns about infant development, maternal physical health and lactation history, as well as those relating specifically to galactagogue use, including: desire for a guaranteed/urgent response, risk-risk trade-off, acceptance and trust, and accessibility and cost. In understanding the complexity of decision-making concerning these substances, we identify opportunities to improve breastfeeding counselling and support. We recommend that support be individually tailored to manage conflicting information, adopt communication styles that encourage trust and processes that enable shared decision-making to enhance or restore maternal agency. There is also considerable need to address evidence gaps regarding the effectiveness and safety of commonly used galactagogues, so that women can be appropriately counselled about potential benefits and harms.

Off-label postpartum use of domperidone in Canada: a multidatabase cohort study

BACKGROUND

Trends in off-label postpartum use of domperidone and the impact of safety advisories on its use remain unknown. Our objectives were to describe postpartum use of domperidone in Canada, to evaluate the impact of Health Canada advisories on prescribing patterns, and to describe the association between domperidone use and a composite end point of sudden cardiac death or ventricular tachycardia (VT) among postpartum patients.

METHODS

We conducted a multidatabase cohort study involving pregnant patients with live births between 2004 and 2017 using administrative health databases from 5 Canadian provinces (British Columbia, Alberta, Saskatchewan, Manitoba and Ontario). We excluded patients with less than 1 year of prepregnancy database history and with approved indications for domperidone. We assessed domperidone use in the 6 months postpartum and the impact of the 2012 and 2015 Health Canada advisories on prescribing via interrupted time series analysis. We estimated crude rates of VT and sudden cardiac death.

RESULTS

We included 1 190 987 live births. Mean maternal age was 28.6 (standard error 0.6) years. Domperidone use increased over time, from 7% in 2003-2005 to 12% in 2009-2011, when it plateaued. The 2012 advisory was followed by a drop in use and a reduction in slope, and the 2015 advisory had a more modest impact. Crude analysis suggests that domperidone may be associated with increased VT or sudden cardiac death (0.74 v. 0.37 per 10 000 person-years; difference per 10 000 person-years: 0.37, 95% confidence interval -0.67 to 1.41).

INTERPRETATION

Postpartum domperidone use increased between 2004 and 2017, with prescribing attenuated after Health Canada advisories and a very low absolute rate of VT or sudden cardiac death. These findings suggest that Health Canada advisories affected prescribing; any potential increase in VT or sudden cardiac death with use of domperidone is small and could not be confirmed in this large study STUDY REGISTRATION: ClinicalTrials.gov, no. NCT04024865.

Effect of Domperidone on Breast Milk Production in Mothers of Sick Neonates: A Randomized, Double-Blinded, Placebo-Controlled Trial

Objective: Mothers of many preterm babies are unable to produce sufficient milk for their babies during the prolonged hospitalization. Domperidone stimulates the release of prolactin, thereby increasing breast milk production. The primary outcome was to study the efficacy of domperidone in augmenting breast milk production in mothers with lactation failure (LF). The secondary outcomes included the effect of domperidone on prolactin levels, adverse effects of domperidone, and outcome on breastfeeding rates at discharge. Materials and Methods: This was a randomized, double-blinded, placebo-controlled trial where mothers with LF were either allocated domperidone (10 mg) or placebo, 2 tablets three times a day for 14 days. Milk volumes were recorded daily for 14 days. Serum prolactin levels were measured at the start and at day 7 of study. Results: Out of 166 women eligible for the study, 119 (71.7%) mothers were able to increase their breast milk production without pharmacological treatment after being counseled on the advantages of human milk and proper breastfeeding management. Forty-seven mothers were finally enrolled in the study; 24 in the domperidone group (DG) and 23 in the placebo group (PG). Breast milk production increased from a baseline of 156 + 141.1 to 400.9 + 239.2 mL in the DG and increased from a baseline of 175.8 + 150.7 to 260.5 + 237.5 mL in the PG, after 14 days (p < 0.01). The prolactin levels in the DG and PG increased from 72.85 (22.2-167.15) and 42.33 (14.02-93.54) ng/mL, respectively, to 223.4 (49.79-280.2) ng/mL (p = 0.005) in the DG and 60.08 (14.31-132.14) ng/mL (p = 0.232) in the PG on the 7th day of treatment. No adverse effects were recorded. Ninety-five percent of babies in the DG were exclusively breastfeeding at hospital discharge, compared with 52.4% in the PG (p = 0.008). Conclusion: Domperidone treatment can result in an increase in breast milk production with no adverse effects. The study was registered with the Thai Clinical Trials Registry ID TCTR2020091008.

Domperidone and the risks of sudden cardiac death and ventricular arrhythmia: A systematic review and meta-analysis of observational studies

AIMS

Concerns exist regarding the cardiovascular safety of domperidone. However, many of the previous studies addressing this issue had important limitations. We aimed to examine domperidone and the risks of sudden cardiac death and ventricular arrhythmia through a systematic review and meta-analysis of observational studies, including an in-depth methodological assessment.

METHODS

We systematically searched MEDLINE, PubMed, EMBASE, Scopus and CINAHL Plus to identify observational studies examining the association of domperidone and sudden cardiac death and/or ventricular arrhythmia. We assessed study quality in duplicate using the ROBINS-I tool supplemented by an assessment of specific biases and the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach. Data were pooled across studies using DerSimonian and Laird random-effects models.

RESULTS

Six case-control studies, 1 case-crossover study and 1 retrospective cohort study were included (n = 480 395). Based on ROBINS-I, 3 studies had moderate risk of bias, 4 had serious risk, and 1 had critical risk. The overall GRADE rating is moderate. When data were pooled across nonoverlapping studies, domperidone was associated with an increased risk of composite endpoint of sudden cardiac death or ventricular arrhythmia compared to nonuse (adjusted odds ratio: 1.69; 95% confidence interval: 1.46, 1.95; I² : 0%; τ² : 0). This association persisted when restricted to higher-quality studies (odds ratio: 1.60; 95% confidence interval: 1.30, 1.97; I² : 0%; τ² : 0).

CONCLUSION

Domperidone is associated with an increased risk of sudden cardiac death and ventricular arrhythmia compared to nonuse. Further investigation comparing domperidone to an active comparator and in younger populations are warranted.

Human Milk Expression After Domperidone Treatment in Postpartum Women: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Insufficient milk production is among the most cited reasons by mothers for discontinuing breastfeeding. Medications that can increase milk production, such as domperidone, an off-label galactagogue, are often prescribed. Domperidone is controversial as it is not approved for any purpose in the United States and is approved only for gastrokinetic purposes in Canada and other countries.

RESEARCH AIM

The aim was to update the existing literature on the efficacy of domperidone as a galactagogue compared to placebo when given to mothers with insufficient human milk production. The primary outcome is the change in expressed human milk volume per day from baseline.

METHODS

The authors independently searched the literature from inception to May 2018. The search included any randomized controlled trials examining the efficacy of domperidone increasing mothers' expressed human milk, measured via a human milk pump. Both authors independently assessed quality and risk of bias and extracted relevant data. Meta-analysis on expressed human milk volume per day was performed.

RESULTS

Seven studies met the inclusion criteria for review; two were excluded from the meta-analysis due to quality grading and insufficient reporting of the outcome of interest. Five studies (N = 239) were combined in the meta-analysis. The effect size showed an increase in the mean difference of expressed human milk volume in mothers given domperidone, 93.97 mL per day (95% CI [71.12, 116.83 mL]; random effect, T² 0.00, I² 0%).

CONCLUSION

This meta-analysis reports a significant improvement in expressed human milk volume per day with the use of domperidone in mothers experiencing insufficient human milk production.

What Evidence Do We Have for Pharmaceutical Galactagogues in the Treatment of Lactation Insufficiency?-A Narrative Review

Inadequate breast milk supply is a frequently reported reason for early discontinuation of breastfeeding and represents a critical opportunity for intervening to improve breastfeeding outcomes. For women who continue to experience insufficient milk supply despite the utilisation of non-pharmacological lactation support strategies, pharmacological intervention with medications used to augment lactation, commonly referred to as galactagogues, is common. Galactagogues exert their pharmacological effects through altering the complex hormonal milieu regulating lactation, particularly prolactin and oxytocin. This narrative review provides an appraisal of the existing evidence regarding the efficacy and safety of pharmaceutical treatments for lactation insufficiency to guide their use in clinical practice. The greatest body of evidence surrounds the use of domperidone, with studies demonstrating moderate short-term improvements in breast milk supply. Evidence regarding the efficacy and safety of metoclopramide is less robust, but given that it shares the same mechanism of action as domperidone it may represent a potential treatment alternative where domperidone is unsuitable. Data on remaining interventions such as oxytocin, prolactin and metformin is too limited to support their use in clinical practice. The review provides an overview of key evidence gaps and areas of future research, including the impacts of pharmaceutical galactagogues on breast milk composition and understanding factors contributing to individual treatment response to pharmaceutical galactagogues.

Domperidone for insufficient lactation in England 2002-2015: A drug utilization study with interrupted time series analysis

PURPOSE

Our aim was to describe trends in the prescription of domperidone for insufficient lactation in England, the characteristics of women prescribed it postpartum, and the impact of a 2014 European Medicines Agency (EMA) recommendation to restrict its use due to a potential increased risk of sudden cardiac death associated with its use.

METHODS

We conducted a population-based cohort study with interrupted time series analysis using data from the Clinical Practice Research Datalink linked to Hospital Episode Statistics. We identified women with live births from 2002 to 2015, excluding those with nonlactation indications for domperidone (n = 247 349). We evaluated trends in the prescription rate of domperidone in the 6 months postpartum and differences in this rate before and after the EMA recommendation.

RESULTS

Domperidone was prescribed among 1438 deliveries at a rate of 1.24 per 100 person-years. This rate increased from 0.56 to 2.1 per 100 person-years between 2002-2004 and 2011-2013 (rate ratio: 3.8; 95% confidence interval [CI], 3.2-4.6). Prescribing decreased in level by 0.35 (95% CI, -0.86 to 0.16) per 100 person-years immediately following the recommendation with little change in trend (0.003; 95% CI, -0.059 to 0.065 per 100 person-years). Following the recommendation, prescription of doses >30 mg and coprescription of drugs with a risk of torsade de pointes decreased. No arrhythmic events were observed among domperidone users.

CONCLUSIONS

Although we observed an important increase in prescribing during the study period, domperidone remains infrequently prescribed postpartum in England. While overall prescribing changed little, some prescribing practices became more restricted following the EMA's recommendation.

Supporting Mothers of Very Preterm Infants and Breast Milk Production: A Review of the Role of Galactogogues

Human milk, either mother’s own milk or donor human milk, is recommended as the primary source of nutrition for very preterm infants. Initiatives should be in place in neonatal units to provide support to the mother as she strives to initiate and maintain a supply of breast milk for her infant. The use of galactogogues are considered when these initiatives alone may not be successful in supporting mothers in this endeavor. Although there are non-pharmacologic compounds, this review will focus on the pharmacologic galactogogues currently available and the literature related to their use in mothers of very preterm infants.

Maternal experiences with and sources of information on galactagogues to support lactation: a cross-sectional study

An increase in the marketing and use of herbal galactagogues among breastfeeding mothers in the US has raised the issue of how best to provide support and information on the use of these products, particularly in light of limited availability of certified lactation counselors and continued suboptimal rates of breastfeeding globally. Currently, no cross-sectional data are available on the experiences and attitudes of mothers regarding the use of herbal and pharmaceutical galactagogues for lactation in the US. The findings of an online survey of 188 breastfeeding mothers on experiences with and sources of information on galactagogues are presented. Most mothers (76%) reported that while breastfeeding, they felt as though they were not making enough milk to meet the needs of their child, and yet 54% also indicated that they had not supplemented with formula. A large proportion of respondents reported utilizing galactagogues to increase lactation and finding them useful. The results indicated that most women learned about galactagogues from the Internet or by word of mouth through friends. Lactation consultants were the third-most reported sources of information on these products. While many respondents reported perceiving galactagogues as innocuous, more evidence on safety and efficacy is needed to support women properly who seek out and use them. Large-scale studies of the prevalence of galactagogue use in the US and rigorous evaluation of use globally are needed to ensure that mothers who choose to breastfeed may safely avail themselves of all options when counseling support is insufficient.