Abstract
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The Lord God took the man and placed him in the garden of Eden to till and tend it. And the Lord God commanded the man saying: “Of every tree of the garden you are free to eat, but as for the tree of knowledge of good and bad you must not eat, for as soon as you eat of it, you shall die.” But as we are subsequently told, for Adam and Eve the temptation was too great and they disobeyed God, rebelled, and sinned by consuming the forbidden fruit, the proverbial apple. Ever since, the term “forbidden fruit” has become a metaphor for an object of desire that is a combination of being unavailable while its' possession is illegal if not immoral.
In this view, it is understandable that the characterization by Dr. Anderson in this month's LactMed column of domperidone as the “Forbidden Fruit” of professional breastfeeding advocates, lactation counselors, and informal lay supporters of breastfeeding is all too accurate. As he details in his comprehensive survey, the appeal of domperidone as a galactogogue stems as much from its quasi-legal state, its clandestine availability, and from previous highly selective anecdotal reports of its efficacy, while all the time downplaying the potential risks and side effects.
Most importantly, as he detailed, the recent Canadian EMPOWER prospective randomized study concluded that although domperidone is a mildly effective galactogogue, it has rare, but serious, adverse reaction risks for the mother. As such, his bottom line was that domperidone (to mix our biblical and postbiblical references) should not be related to as the holy grail for resolving problems of supposed “inadequate milk supply.” The solution, as he notes, to breastfeeding problems, is to focus on best practices and to provide maternal reassurance and support. Such an approach rather than prescribing a galactogogue will be in his opinion a more fruitful way of ensuring an adequate maternal milk supply. In other words one should strive to recreate the Edenic era and “tend and till” the garden and abhor the forbidden fruit.
The possible futile quest for a holy grail with magical and miraculous powers that can resolve the realities of disease and discomfort and provide unbounded sustenance is more than alluded to in this month's ABM Protocol (#22) that addresses the management issues of jaundice in the term and late preterm infant. Again most importantly, the authors emphasize the need to manage the issue of jaundice in the newborn in a physiological and supportive manner to ensure optimal health, growth, and development of the infant. In the words of the protocol, a complete understanding of normal and abnormal states of both bilirubin and breastfeeding is essential “if optimal care is to be provided and the best outcome achieved for the child.” What that means in a practical way is not taking the “easy way out” or seeking magical cures. In other words, reflexively initiating phototherapy, routinely stopping breastfeeding, and/or supplementing with formula are not another holy grail of treatment. Treatment should be personalized, individualized, and flexible, surely, if we maintain the biblical motif, “it should not be chiseled in stone.”