Medications with an antidopamine effect, such as phenothiazine, haloperidol, and other neuroleptics, such as sulpiride and risperidone, as well as the antihypertensive a-methyldopa, and medications used to stimulate intestinal peristalsis, domperidone and metoclopramide, can, as a result of increasing the secretion of prolactin, stimulate milk production. The sympatholytic action of reserpine can have the same effect. Growth hormone and thyrotrophin-releasing hormone can also enhance milk production. Domperidone and metoclopramide are occasionally used for this purpose - for example. 10 mg metoclopramid three times a day (for a maximum of 7-10 days) and then tapering off the dosage for 2-5 days is sometimes recommended. Domperidone (not available in the USA) is less capable of crossing the blood-brain barrier, and therefore the risk of extrapyramidal symptoms is remote. Due to a molecular mass of 426, protein binding >90%, and poor oral bioavailability, the relative dose for a fully breastfed child is only 0.4% (see section 4.3.3). A dose of 50 mg of sulpiride two to three times a day, or 10 mg of chlorpromazine three times a day, have also been tried (Hallbauer 1997). Extrapyramidal symptoms and tiredness in the mother make the use of the latter two medications questionable. In addition, it has been repeatedly reported that individual psychological and technical support of the mother is as successful as prolactin-activating medication in resolving breastfeeding problems, or even with relactation (see, for example, Seema 1997).
Oxytocin stimulates the milk ejection reflex (also called the letdown reflex). For this reason, and because it also encourages uterine involution, it is the drug of choice for the often painful engorgement. Amphetamines, diuretics, estrogen and dopamine agonists from the group of ergotamine derivatives - such as, for instance, bromocriptine, cabergolin, lisuride, methylergometrine (methylergonovine), pergolide, and the drug quinagolide. all of which have an antiprolactin action -can reduce the production of milk. The various prostaglandins have been observed both to enhance and impede milk production. Alcohol and opiates cause a decline in the milk ejection due to reduction in the release of oxytocin.
Bromocriptine is used especially for weaning. However, the possible risks for the mother should lead to its cautious use. Because of the possible cardiovascular side effects, the American Food and Drug Administration (FDA) has rescinded the (earlier) permission to prescribe bromocriptine for weaning. Physical measures such as wellfitted supportive clothing, cooling, and emptying the breast until the mother feels relieved are preferable to ergotamine derivatives. In the case of mastitis, recommendations are bed rest, frequent emptying of the breast (after first using heat), and cooling it afterwards, as well as antibiotic therapy in some cases. Binding the breasts is no longer recommended because of the danger of engorgement. However, mothers are instructed to wear firm-fitting brassieres.
High-dosage estrogen is no longer used for weaning because of the risk of thromboembolism. The low estrogen content in the oral contraceptives which are available today limit milk production, if at all, only then when lactation is already poorly established. Pure gestagen contraceptives have no influence on the amount of milk produced.
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