Joy, your message about metoclopramide made me sit up and take notice!  You
raised several insightful points about this drug that sound so similar to
the effects of sulpiride.  I know I keep sending messages about this drug,
please everyone skip if you are getting bored with it!

Sulpiride is used *very* frequently here and in South Africa to boost a
flagging milk supply.  It is registered as an anti-depressant, but its
side-effect is that it increases/enhances lactation by raising prolactin
levels.  I have heard anecdotal reports of even men lactating while taking
this drug.  I believe it is very similar to metoclopramide (both being
derivatives of procainamide, I think, but haven't looked this up for a
while, so may be wrong!).  I know very little about metoclopramide, but I
have been "collecting" observations and anecdotal reports about the effects
of sulpiride for seven years and will comment on your post as if you were
asking about sulpiride and perhaps you will notice the similarities.

You wrote: "I have always assumed that, like bromocriptine, metaclopramide
has the most effect on lactation in the early stages of lactation. This is
because these drugs act on prolactin levels, and that's the time when
prolactin is most important to the process. After the initial weeks, the
autocrine control is what keeps things going, mainly."

My observation is that sulpiride prescribed *very* early (say 2 - 3 days
postpartum) seems to have very little effect, I assume that this is because
prolactin levels are already high.  It may however exacerbate engorgement at
this time.  It seems to be helpful in cases where Lactogenesis II seems to
be delayed (haemorrhage, possible retained placenta).  It can be stopped
abruptly in the first 5 - 6 days without having a negative effect on lactation.

You wrote "I recently heard about a mum who was still breastfeeding a
23-month-old .. taking metaclopramide .. she suddenly has masses of milk and
engorgement - similar to milk coming in in the early days".  Taking
sulpiride later in lactation *does* seem to increase breastmilk production
for a short time.  However, if mom takes the drug and doesn't drain the
breasts frequently, the increased supply appears to be short-lived.  I
assume this is because drainage has a greater effect on later lactation than
prolactin levels.

You wrote, "In another case, a pregnant mum suddenly started leaking
milk after taking metaclopramide.".   Now *this* is interesting!  I have
never heard of a preg mom being prescribed sulpiride.  It is surprising that
the hormones secreted by the placenta do not continue to inhibit lactation -
after all, we know that during late pregnancy prolactin levels are already high.

You wrote, "does this mean that a mum could get this effect at *any* time
when her breasts are primed for lactation? How useful would this be to boost
milk supply in mothers several weeks or months down the track?"

Yes, yes, yes!!  Sulpiride *does* seem to boost the milk supply *any* time
when the breasts are primed for lactation.  And yes, it *is* extremely
useful.  However, as mentioned, the drug alone does not seem to have this
effect for long - the breasts *must* be drained frequently and thoroughly or
the supply dwindles again.  I find this situation maddening.  Mothers here
are so familiar with this drug (it is prescribed like smarties, and is in
effect available almost "on demand") that they go to their doctors and ask
for "those milk pills".  Kindly doctor happily prescribes a quick two-week
course without finding out the original cause of low milk production, mom
continues to breastfeed 4-hourly, or whatever, is delirious about the good
results, becomes very complacent, then feels devastated when 4 days after
the last pill her milk supply dwindles dramatically.  Some of the doctors
give advice to tail off, some don't.  I can find absolutely *no* research
showing what happens to lactation when sulpiride is *stopped*.  We also have
mothers giving unused pills to their friends, to "help" them with their milk
supply, and all kinds of other abuse!

One or two additional observations.  Sulpiride seems to take 4 - 5 days to
start working well, i e for a noticeable increase in breastmilk production
to occur.  The MOST IMPORTANT part of this "treatment" is that sulpiride
MUST be tailed off very slowly or breastmilk production appears to be badly
affected - again, about 4 - 5 days after the last dose.  It can be extremely
helpful for moms in very special circumstances who are highly motivated to
breastfeed and who will put in the time and effort on drainage but would
benefit from a "boost" to their prolactin levels to achieve quicker results.
(I am thinking of long-term pumping e g for very prem babies, or building a
good milk supply for FTT babies, or to induce lactation for adoptive
nursing). I have known moms take one capsule per day for several months
because they get psychologically "hooked" on this drug and don't believe
they can make milk without it, and I had a personal friend nursing a toddler
who took it for three *years*!  However, in most cases a mom can take
sulpiride until she is happy with her milk supply and then tail it off
gradually and continue to produce adequate milk for her baby.  I have
absolutely no idea why this drug is so commonly used in Southern Africa, but
seems *not* to be used elsewhere in the world.  Appropriately prescribed and
in conjunction with an individualized care plan for *this* mother and *this*
baby IMO it is a useful tool.

The big question, Joy, is whether metoclopramide *does* behave in a similar
way. My "hunch" (based on yours and others' observations reported on
Lactnet) is that it does.

Pamela Morrison IBCLC, Zimbabwe