Case report of preparation for induction of lactation in a cisgender woman (NDC Clinical Guidelines)

The case of AB, who is CD's partner, is blended from different real cases, and anonymised.

Letter back to the referring general practitioner

Thank you for referring AB, an X-year-old woman [in her early 30s], to discuss induction of lactation. AB's partner CD is 22 weeks pregnant with their child, conceived by intrauterine insemination using donor sperm.

AB saw me for lactation induction in the hope of bonding with their baby. The couple are also planning to alternate breastfeeding to limit the burden on CD. AB would like to prepare her breasts for milk production, which she hopes to commence prior to the baby’s birth, with a view to storing milk.

Although CD is aware that [particular elements in] her past medical history may impact upon her capacity to exclusively breastfeed the baby, we don’t know that for sure, and this will only become clear once CD begins to breastfeed.

Medical history and current medications

AB has no risk factors which would contra-indicate combined oral contraceptive pill use. She has never previously taken contraceptive pills.

AB has a history of anxiety, which has been stable for years, and is currently taking sertraline 50 mg day. Sertraline is not a contra-indication for domperidone use, but a small percentage of women do describe mood changes with domperidone. AB takes no other medications which could contra-indicate the use of domperidone.

It may be, given how well AB has been, that she discusses with you a very gradual weaning off the sertraline, at the same time as she gets underway with hormones and domperidone, but I hand that decision over to AB in discussion with you.

AB has no other medical history which would pose contra-indications to the OCP. She has no personal or family history of cardiac arrythmias.

AB's ECG is normal.

NDC protocol for induction of lactation, adapted for AB

The NDC protocol for induction of lactation can be adapted to best suit the individual needs of each patient. Preparation of the breasts commences 16 weeks prior to date of infant's arrival.

1. Preparation of breasts with 10 week course of combined oestrogen and progesterone

There is no evidence to suggest that exposing the mammary glandular tissue to an oral contraceptive pill will improve breastmilk production outcomes.

I recommend that AB commences a 10 week course of Yasmin (drospirenone 3000 micrograms (mcg) + ethinylestradiol 30 mcg) daily. The Yasmin is to be taken continuously (active pills only, no sugar pills).

• Yasmin can result in break through bleeding, requiring only reassurance.

• Yasmin may have a mild diuretic effect.

• After a month or so of taking Yasmin, it is likely that AB's breasts will start to feel tender, full and heavy.

I have suggested 2.5 months of hormones knowing that 30-60 days is generally considered minimal effective stimulation by hormones, though none of this has been researched.

2. Preparation of breasts with domperidone

There is evidence demonstrating that domperidone improves breast milk production in women whose infant is born prematurely. There is no evidence to suggest that a higher dose (20 mg tds) of domperidone is more effective. A higher dose is likely to increase the risk of side-effects.

I recommend that AB

• Commence domperidone at the same time as she commences Yasmin

• Takes 10 mg of domperidone three times daily for one week, increasing to 20 mg three times daily

• Takes domperidone half an hour before meals for best absorption.

3. Preparation of breasts by mechanical vacuum application and milk removal

Nipple stimulation by pumping is the most powerful way to build a milk supply. The hormones are intended to prepare AB's breasts to respond as effectively as possible prior to the nipple stimulation.

Six weeks prior to the baby’s due date

• Cease the combined oral contraceptive pill. This is intended to mimic giving birth (at which time progesterone and oestrogen levels dramatically drop). Stopping six weeks before the due date gives AB enough time to build a supply through pumping, even if the baby arrives two weeks early.

• Begin regular pumping of the breasts. Mechanical vacuum application mimics baby’s suckling.

I recommend that AB

• Invests in a hospital-grade double pump

• Pumps every three hours during the day, and also once in the night.

It’s helpful for AB to remember that it is not long durations of pumping which matter, but the frequency. Short (perhaps ten minutes) but more frequent (every couple of hours or so) pumps are likely to be more effective than 15 minutes or longer, six or eight times in a day. Because AB will be pumping for such a long period of time, it is important to do pumping in a way that works for her. It doesn’t have to be strictly regulated, just frequent, when she can.

AB has already purchased a high grade double-flanged pump. In our consultation, I demonstrated how to use a pump.

4. After baby arrives

After the baby is born, I recommended that AB create opportunities for skin-to-skin contact. Frequent flexible access of baby to the breast is great for building milk production, but AB and CD will work out the way they plan to do this to suit their family, since CD intends to build her breast milk supply, as a priority.

At the time of the baby’s birth, AB has said she would hope to be joining CD in offering their baby lots of skin-to-skin contact. AB also hopes to offer the baby her breast, in a way that works for her and CD and the baby.

It will be important for AB to continue pumping after the baby’s birth to optimise her supply. Although the baby is ‘the best pump’, AB will need to continue pumping including after feeds or pumping flexibly between feeds, still aiming for 6-8 or so pumps both breasts each day in addition to feeds.

If the baby is not direct breastfeeding from AB at all, at least 8 pumps both breasts in a 24 hour period is expected to maintain supply. There is no right or wrong with this, just what works for AB, remembering that milk removal frequently and flexible (though not necessarily for long periods) is important to build or maintain supply.

After a few weeks with AB offering each of her breasts to the baby at least eight times in a 24-hour period, and also pumping, she may decide that she is ready to gradually stop mechanical milk removal.

5. Continue domperidone use for at least 8 weeks after the baby’s birth then cease by tapering the dose

I would recommend that AB continues the domperidone 20 mg three times daily for at least the first 8 weeks of the baby’s life. Once AB feels that her milk production has peaked and she is able to maintain it in a stable way, she may begin to wean off the domperidone.

It is important to wean off gradually because of its potential effect on the serotonergic axis. Side-effects of nausea, anxiety, trembling can occur with weaning off domperidone.

A particularly cautious taper of domperidone is recommended for a patient who is on sertraline. I recommend the following taper:

Week	Morning (mg)	Afternoon (mg)	Evening (mg)
1	20	20	20
2	20	10	20
3	20	10	10
4	10	10	10
5	10	0	10
6	5	0	5
7	Cease

It can be reassuring to know that even for successfully breastfeeding women who have carried a baby to term, their prolactin level drops off rapidly after the birth, and prolactin levels are not an indicator of milk supply (unless the woman has a medical condition which causes extremely high or extremely low levels).

The most important thing with the older baby is to continue frequent milk removal, whether it’s by the baby’s suckling or by the pump, to maintain milk production.

6.There is no evidence to support the use of fenugreek, herbs or extra water intake in induction of lactation

Conclusion

AB requires a blood pressure check 6-8 weeks into the hormone treatment.

Both CD and AB would be welcome to see me for an appointment immediately after the birth of the baby if they wished, for optimising breastfeeding.

Thank you very much referring AB to The Possums Clinic, and I wish AB and CD a wonderful journey into parenthood!

Kind regards

Pamela Douglas