Hi Kathleen, I am so interested in this Reglan thing.  WHY is it not
recommended for longer than two weeks? (Hale, 96 edition)  This is
metoclopramide, a drug that is given to infants for gastroesophageal reflux,
right?  When it is used in children for GE reflux, is it also discontinued
after 10 days?  The reason for this mom's apparent lactation failure could
simply be that the drug was discontinued too soon. What a crying shame!

In Zimbabwe we use a very similar drug to metoclopramide as a galactogogue,
called sulpiride (Trade names Eglonyl made by Noristan, or Equemote, a
locally produced equivalent).  During my first year of practice 27% of my
clients had been prescribed sulpiride for the current or a previous
lactation - so it is *commonly* used here.   According to one study (Ref 3
below) sulpiride acts as a dopamine antagonist at central nervous system and
pituitary levels and stimulates the secretion of prolactin in normal
subjects as well as in puerperal women.  According to another study (Ref 2
below)  sulpiride has few side effects in either mother or child.
Sulpiride is also used extensively in South Africa. I realize that it is not
used in other parts of the world, but I wonder why not?
It is registered as an anti-depressant, but it's side effect is that it
enhances lactation, so it can be really helpful for those moms - like yours
Kathleen - who might have marginal breastmilk supplies. Breast drainage
needs to frequent and thorough.  If mom expects to only need to breastfeed
every 4 hours while taking it there seems to be an initial increase, but
production declines again within a few days, obviously as any normal
breastmilk supply would, from lack of drainage.   The usual dosage is 50 mg
3x/day for two weeks, and then I ask my moms to get a repeat prescription in
order to take 2/day for a week then 1/day for a week in order to taper off.
If they have already experienced a severe reduction in supply because of
abrupt withdrawal of sulpiride then starting a new course from the beginning
usually works.  Moms sometimes take it for months, and I had a personal
friend who took it for three *years* while nursing a toddler.  I think these
moms get psychologically hooked on it, though there does not seem to be a
physical addiction. The manufacturers say that sulpiride can be used in
children at the doseage 1 - 3 mg/kg three times daily.

My observation of the effects of this drug are (1) it takes about 4 days to
kick in (for breastmilk production to be enhanced),  (2) mom needs to
continue taking it until she is happy with her milk supply, (3) once this
has happened, it needs to be tapered off very gradually (4) stopping
abruptly can lead to depression and lactation failure 4 - 10 days after the
last dose (5) it will only double what is already there, i e in cases where
lactogenesis simply does not occur, it will not help.

From reading so much on Lactnet about Reglan, it strikes me that there is a
great similarity between Reglan (metoclopramide) and sulpiride, in the way
it enhances prolactin levels to increase lactation and in the negative
effect on lactation if it is discontinued too soon.  However, there seems to
be much more caution in the use of metoclopramide in the US than in the use
of sulpiride in Zimbabwe and South Africa. A quick glance at the
manufacturers lists of side effects and special precautions of both drugs in
my MIMS (South African desk reference on drugs) shows that there are more
for metoclopramide and fewer for sulpiride.

The effects of sulpiride and of metoclopramide (and other drugs) on
lactation were studied in the l980s (refs below) often by the same
researchers, but sulpiride and metoclopramide were not actually compared.  I
wonder why metoclopramide has caught on as a short-term galactogogue in the
US, but long-term sulpiride has not? If we are looking at risk/benefit
ratios, surely breastmilk laced with a little metoclopramide or sulpiride is
infinitely preferable to the use of formula when lactation needs a little
boost?  There's a further research study in there somewhere, if we could
persuade any of our pharmacology experts to take this further.

Refs for sulpiride

1.  Mancini AM, Guitelman A, Vargas CA, Debeljuk L, Aparicio NJ: Effect of
sulpiride on serum prolactin in humans.  J Clin Endocrinol Metab 42:1881-4, 1976

2.  Aono T, Shioji T, Aki T, Hirota K, Nomura A and Kurachi K: Augmentation
of puerperal lactation by oral administration of sulpiride, J Clin.
Endocrinol. Metab. 48:487, 1979

3.  Aono T, Aki T, Koike K, et al:  Effect of sulpiride on poor puerperal
lactation, Am J Obstet. Gynecol. 143:927, 1982

4.  Ylikorkala O, Kauppila A, Kivinen S, et al: Sulpiride improves
inadequate lactation.  Br Med J 285:299, 1982

5.  Ylikorkala O, Kauppila A, Kivinen S and Viinikka L, Treatment of
inadequate lactation with oral sulpiride and buccal oxytocin.  Obstet
Gynecol 63:57, 1984

Refs for metoclopramide

6.  Kauppila A, Kivinen S, Ylikorkala O: A dose response relation between
improved lactation and metoclopramide.  Lancet i:1175-7, 1981

7.  Kauppila A, Kivinen S, Ylikorkala O: Metaclopramide increases prolacting
release and milk secretion in puerperium without stimulating the secretion
of thyrotropin and thyroid hormones.  J Clin Endocrinol Metab 52:436, 1981.

8.  Kauppila A et al;  Metoclopramide and breast feeding: Transfer into
human milk and the newborn.  Eur J Clin Pharmacol. 25:819-23, 1983

Pamela Morrison IBCLC, Zimbabwe
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