MEDICATIONS AND MEDICATIONS AND

BREASTFEEDING: BREASTFEEDING: BREASTFEEDING: BREASTFEEDING:

What Dispensing Pharmacists What Dispensing Pharmacists
Need To Know Need To Know
Frank J . Nice, RPh, DPA, CPHP Frank J . Nice, RPh, DPA, CPHP
Derwood, MD 20855 Derwood, MD 20855
fjncat@hotmail.com fjncat@hotmail.com
www.nicebreastfeeding.com www.nicebreastfeeding.com gg
301 301--840 840--0270 (H) 0270 (H)
240 240--506 506--2568 (C) 2568 (C)
OBJ ECTIVES OBJ ECTIVES OBJ ECTIVES OBJ ECTIVES
Be able to identify the benefits and risks of Be able to identify the benefits and risks of yy
medication use during breastfeeding medication use during breastfeeding
Be able to identify available resources for Be able to identify available resources for
di ti d i b tf di di ti d i b tf di medication use during breastfeeding medication use during breastfeeding
Be able to utilize tools and techniques for Be able to utilize tools and techniques for
evaluating medication use during breastfeeding evaluating medication use during breastfeeding evaluating medication use during breastfeeding evaluating medication use during breastfeeding
Be able to identify adverse effects in children of Be able to identify adverse effects in children of
mothers who are breastfeeding and taking mothers who are breastfeeding and taking
di ti di ti medications medications
Be able to counsel mothers who are Be able to counsel mothers who are
breastfeeding and taking or will take medications breastfeeding and taking or will take medications
22
breastfeeding and taking or will take medications breastfeeding and taking or will take medications
Photo Courtesy of NIH Photo Courtesy of NIH 33
Benefit Benefit--Risk Analysis Risk Analysis Benefit Benefit Risk Analysis Risk Analysis
Benefits of breastfeeding (See Handout) + Benefits of breastfeeding (See Handout) + Benefits of breastfeeding (See Handout) + Benefits of breastfeeding (See Handout) +
Benefits of the drug (from the package Benefits of the drug (from the package
insert and/or literature) insert and/or literature)
Versus Versus
Risks of formula use or NOT breastfeeding Risks of formula use or NOT breastfeeding gg
(See Handout) + Risks of the drug (from (See Handout) + Risks of the drug (from
the package insert and/or literature) the package insert and/or literature)
44
SOURCES OF INFORMATION SOURCES OF INFORMATION SOURCES OF INFORMATION SOURCES OF INFORMATION
Journal Articles Journal Articles
Nice References Nice References Nice References Nice References
AAP Committee on Drugs AAP Committee on Drugs (See Website List) (See Website List)
MICROMEDEX (See Website List) MICROMEDEX (See Website List)
Books Books Books Books
NNonprescription Drugs for the Breastfeeding Mother, 2 onprescription Drugs for the Breastfeeding Mother, 2
nd nd
Edition Edition
Nice (See Slide) Nice (See Slide)
Medications and Mothers Milk 15 Medications and Mothers Milk 15
th th
Edition Edition Medications and Mothers Milk, 15 Medications and Mothers Milk, 15 Edition Edition
Hale Hale (See Slide) (See Slide)
Drugs in Pregnancy and Lactation, 9 Drugs in Pregnancy and Lactation, 9
th th
Edition Edition
Briggs, Freeman, and Yaffe (See Slide) Briggs, Freeman, and Yaffe (See Slide)
Drugs and Human Lactation, 2 Drugs and Human Lactation, 2
nd nd
Edition Edition
Bennett (WHO) Bennett (WHO)
55
66
77
88
99
SOURCES OF INFORMATION SOURCES OF INFORMATION SOURCES OF INFORMATION SOURCES OF INFORMATION
Pharmaceutical Companies Pharmaceutical Companies Pharmaceutical Companies Pharmaceutical Companies
Websites Websites (See Next Slide) (See Next Slide)
Lactation Study Center Lactation Study Center Lactation Study Center Lactation Study Center
Ruth Lawrence, MD Ruth Lawrence, MD
University of Rochester University of Rochester University of Rochester University of Rochester
601 Elmwood Avenue, Rochester, NY 14642 601 Elmwood Avenue, Rochester, NY 14642
(585) 275 (585) 275--0088; Mon 0088; Mon--Fri 8AM Fri 8AM--5PM 5PM (585) 275 (585) 275 0088; Mon 0088; Mon Fri, 8AM Fri, 8AM 5PM 5PM
10 10
BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES
Nice Breastfeeding Nice Breastfeeding
www.nicebreastfeeding.com www.nicebreastfeeding.com
LactMed / TOXNET / NLM/ NIH LactMed / TOXNET / NLM/ NIH LactMed / TOXNET / NLM / NIH LactMed / TOXNET / NLM / NIH
http://toxnet.nlm.nih.gov/cgi http://toxnet.nlm.nih.gov/cgi--
bi / i /ht l ?LACT bi / i /ht l ?LACT bin/sis/htmlgen?LACT bin/sis/htmlgen?LACT
Thomas Hale InfantRisk Center Thomas Hale InfantRisk Center
http://www.infantrisk.com/category/ http://www.infantrisk.com/category/
breastfeeding breastfeeding
11 11
breastfeeding breastfeeding
BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES
Breastfeeding Online Breastfeeding Online
http://breastfeedingonline.com http://breastfeedingonline.com
KellyMom KellyMom yy
http://www.KellyMom.com http://www.KellyMom.com
American Academy of Pediatrics Policy Statement: The Transfer of American Academy of Pediatrics Policy Statement: The Transfer of American Academy of Pediatrics Policy Statement: The Transfer of American Academy of Pediatrics Policy Statement: The Transfer of
Drugs and Other Chemicals Into Human Milk Drugs and Other Chemicals Into Human Milk
http://aappolicy.aappublications.org/cgi/ http://aappolicy.aappublications.org/cgi/
content/full/pediatrics%3b108/3/776 content/full/pediatrics%3b108/3/776 pp
MICROMEDEX Healthcare Series MICROMEDEX Healthcare Series
(Subscription Required) (Subscription Required)
12 12
(Subscription Required) (Subscription Required)
http://www.micromedex.com/products/hcs/ http://www.micromedex.com/products/hcs/
DRUG FACTORS DRUG FACTORS--II
G l G id li G l G id li General Guidelines General Guidelines
1. 1. Most drugs appear in breast milk to some degree Most drugs appear in breast milk to some degree
22 Levels of most drugs in breast milk do not usually Levels of most drugs in breast milk do not usually 2. 2. Levels of most drugs in breast milk do not usually Levels of most drugs in breast milk do not usually
exceed 1% to 2% of ingested maternal dosage exceed 1% to 2% of ingested maternal dosage
33 If the milk/plasma ratio of drug and active If the milk/plasma ratio of drug and active 3. 3. If the milk/plasma ratio of drug and active If the milk/plasma ratio of drug and active
metabolites is less than 1:1, it is metabolites is less than 1:1, it is usually usually safe to safe to
breastfeed breastfeed
4. 4. If infant dose is less than 10% of maternal dose If infant dose is less than 10% of maternal dose
(weight adjusted), it is usually safe to breastfeed (weight adjusted), it is usually safe to breastfeed
13 13
DRUG FACTORS DRUG FACTORS--II II
Pharmacokinetics Pharmacokinetics
1. 1. Volume of Distribution Volume of Distribution
(1 (1--20 L/Kg) 20 L/Kg)
pH (breast milk more acidic) pH (breast milk more acidic) 2. 2. pH (breast milk more acidic) pH (breast milk more acidic)
3. 3. Lipids Lipids
44 Protein Protein--BoundDrugs (85%) BoundDrugs (85%) 4. 4. Protein Protein--Bound Drugs (85%) Bound Drugs (85%)
5. 5. Molecular Size (Daltons) Molecular Size (Daltons)
(200 (200--400) 400)
6. 6. Active Transport Active Transport
14 14
MATERNAL FACTORS MATERNAL FACTORS
Pharmacodynamics Pharmacodynamics
1. 1. Mammary epithelium may have drug Mammary epithelium may have drug --
metabolizing capacity metabolizing capacity g p y g p y
2. 2. Milk volume is usually greatest in the Milk volume is usually greatest in the
early morning early morning early morning early morning
3. 3. Fat content of milk is usually highest in Fat content of milk is usually highest in
the late morning the late morning
44 Stage of breastfeeding is factor Stage of breastfeeding is factor
15 15
4. 4. Stage of breastfeeding is factor Stage of breastfeeding is factor
Stage of Breastfeeding Stage of Breastfeeding Stage of Breastfeeding Stage of Breastfeeding
Newborns feed every 1 Newborns feed every 1--2 hours 2 hours Newborns feed every 1 Newborns feed every 1 2 hours 2 hours
Colostrum (0 Colostrum (0- -3 days) 3 days)
T iti l Milk (4 T iti l Milk (4 7 d ) 7 d ) Transitional Milk (4 Transitional Milk (4--7 days) 7 days)
Mature Milk (7 Mature Milk (7- -10 days) 10 days)
Alveolar Spaces (0 Alveolar Spaces (0- -7 days) 7 days)
16 16
INFANT FACTORS INFANT FACTORS
Pharmacodynamics Pharmacodynamics
1. 1. Infants ability to absorb drug Infants ability to absorb drug
Infants ability to detoxify and excrete Infants ability to detoxify and excrete 2. 2. Infants ability to detoxify and excrete Infants ability to detoxify and excrete
the drug the drug
17 17
Photo Courtesy of NIH Photo Courtesy of NIH 18 18
QUESTIONS TO ASK IN
DRUG / BREASTFEEDING SITUATIONS
1. What is the name, strength, and dosage of the drug?
2. Do you still have the prescription? Or, have you already
filled it and are taking the drug?
3. Why is the drug being prescribed?
4. Do you feel you need to take the drug?
5. What does your doctor say regarding breastfeeding y y g g g
outcome and taking the drug?
6. What is the drug dosage schedule and how often do
19 19
you nurse?
QUESTIONS TO ASK IN
DRUG / BREASTFEEDING SITUATIONS
(continued)
7. How old is your baby?
8. Was your baby full-term or premature?
9. What is your baby's weight?
10. Is your baby currently receiving any medication?
11. Do you knowhowto hand-express breast milk or 11. Do you know how to hand express breast milk or
do you have access to a breast pump?
12. Is this your first breastfed baby?
20 20
y y
STEPWISE APPROACH TO MINIMIZING INFANT
DRUG EXPOSURE
1. Withhold the drug
2. Try nondrug therapy
3. Delay therapy
4. Choose drugs that pass poorly into breast milk 4. Choose drugs that pass poorly into breast milk
5. Choose more breastfeeding compatible
dosage forms dosage forms
21 21
STEPWISE APPROACH TO MINIMIZING STEPWISE APPROACH TO MINIMIZING
INFANT DRUG EXPOSURE INFANT DRUG EXPOSURE INFANT DRUG EXPOSURE INFANT DRUG EXPOSURE (continued) (continued)
66 Choose an alternative route of Choose an alternative route of 66.. Choose an alternative route of Choose an alternative route of
administration administration
77 Avoid nursing at times of peak drug Avoid nursing at times of peak drug 7. 7. Avoid nursing at times of peak drug Avoid nursing at times of peak drug
concentrations in milk concentrations in milk
88 Administer drug immediately after Administer drug immediately after 8. 8. Administer drug immediately after Administer drug immediately after
breastfeeding and / or before infant's breastfeeding and / or before infant's
l t l l t l longest sleep longest sleep
9. 9. Temporarily withhold breastfeeding Temporarily withhold breastfeeding
22 22
10. Discontinue breastfeeding (wean) 10. Discontinue breastfeeding (wean)
Photo Courtesy of NIH Photo Courtesy of NIH 23 23
CASE STUDY CASE STUDY CASE STUDY CASE STUDY
Mrs Maine a breastfeeding woman Mrs Maine a breastfeeding woman Mrs. Maine, a breastfeeding woman, Mrs. Maine, a breastfeeding woman,
presents a prescription. She is presents a prescription. She is
worried about taking this medication worried about taking this medication worried about taking this medication worried about taking this medication
while breastfeeding and asks for my while breastfeeding and asks for my
recommendation She wants to know recommendation She wants to know recommendation. She wants to know recommendation. She wants to know
if the antibiotic is safe to take while if the antibiotic is safe to take while
breastfeeding her baby Augusta breastfeeding her baby Augusta breastfeeding her baby, Augusta. breastfeeding her baby, Augusta.
24 24
CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued)
After asking the mother several questions After asking the mother several questions After asking the mother several questions After asking the mother several questions
about herself and her baby, the mother about herself and her baby, the mother
states that she will be back in two hours to states that she will be back in two hours to states that she will be back in two hours to states that she will be back in two hours to
pick up her filled prescription if I determine pick up her filled prescription if I determine
that the drug is usually safe to take while that the drug is usually safe to take while that the drug is usually safe to take while that the drug is usually safe to take while
breastfeeding. breastfeeding.
What questions should be asked the What questions should be asked the What questions should be asked the What questions should be asked the
mother? mother?
25 25
CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued)
Fromthe mother I was able to obtain the Fromthe mother I was able to obtain the From the mother, I was able to obtain the From the mother, I was able to obtain the
following information: following information:
The mother weighs 110 pounds (50 Kg) The mother weighs 110 pounds (50 Kg) The mother weighs 110 pounds (50 Kg). The mother weighs 110 pounds (50 Kg).
The mother and baby have no drug The mother and baby have no drug
allergies Her baby is seven months old allergies Her baby is seven months old allergies. Her baby is seven months old, allergies. Her baby is seven months old,
taking no medications, and weighs 22 taking no medications, and weighs 22
pounds (10 Kg) Breastfeeding is going pounds (10 Kg) Breastfeeding is going pounds (10 Kg). Breastfeeding is going pounds (10 Kg). Breastfeeding is going
very well. very well.
26 26
CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued)
The prescription is for: Xybotic The prescription is for: Xybotic The prescription is for: Xybotic, The prescription is for: Xybotic,
1000 mg every twelve hours for five 1000 mg every twelve hours for five
d (2000 d ) d (2000 d ) days (2000 mg per day). days (2000 mg per day).
27 27
CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued)
I amunable to find any AAP I amunable to find any AAP I am unable to find any AAP I am unable to find any AAP
recommendation regarding Xybotic. recommendation regarding Xybotic.
What is my next step? What is my next step?
28 28
CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued)
I run a computer search on Xybotic and I run a computer search on Xybotic and I run a computer search on Xybotic and I run a computer search on Xybotic and
come up with the following information: come up with the following information:
Xybotic is 90 percent bound to plasma Xybotic is 90 percent bound to plasma Xybotic is 90 percent bound to plasma Xybotic is 90 percent bound to plasma
protein, has a fairly low fat solubility, has a protein, has a fairly low fat solubility, has a
volume of distribution of 1400 L has a volume of distribution of 1400 L has a volume of distribution of 1400 L, has a volume of distribution of 1400 L, has a
molecular mass (size) of 300 Daltons, molecular mass (size) of 300 Daltons,
peaks in plasma in one hour and has a peaks in plasma in one hour and has a peaks in plasma in one hour, and has a peaks in plasma in one hour, and has a
half half--life of four hours. life of four hours.
29 29
CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued)
Protein: + Protein: + Protein: Protein:
Fat Solubility: + Fat Solubility: +
Daltons: +/ Daltons: +/ Daltons: +/ Daltons: +/--
Volume of Distribution: + Volume of Distribution: +
P k A id b tf di 0 P k A id b tf di 0 2 h ft 2 h ft Peak: Avoid breastfeeding 0 Peak: Avoid breastfeeding 0--2 hours after 2 hours after
dose, if possible dose, if possible
H lf H lf Lif Sh ld t l t i b b Lif Sh ld t l t i b b Half Half--Life: Should not accumulate in baby Life: Should not accumulate in baby
30 30
CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued)
I also amable to find a reference to one I also amable to find a reference to one I also am able to find a reference to one I also am able to find a reference to one
study that states that when five mothers study that states that when five mothers
took Xybotic an average of 0 01 mg of took Xybotic an average of 0 01 mg of took Xybotic, an average of 0.01 mg of took Xybotic, an average of 0.01 mg of
the drug appeared in 1 ml (10 mg/L) of the drug appeared in 1 ml (10 mg/L) of
breast milk breast milk breast milk. breast milk.
Mothers wt. adjusted dose: 40mg/Kg/day Mothers wt. adjusted dose: 40mg/Kg/day
B b t dj t d d 1 /K /d B b t dj t d d 1 /K /d Babys wt. adjusted dose: 1 mg/Kg/day Babys wt. adjusted dose: 1 mg/Kg/day
Baby/Mother Percentage = 2.5% (1/40) Baby/Mother Percentage = 2.5% (1/40)
31 31
Photo Courtesy of NIH Photo Courtesy of NIH 32 32
CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued)
What recommendation would you What recommendation would you What recommendation would you What recommendation would you
provide to Mrs. Maine as you counsel provide to Mrs. Maine as you counsel
h ? h ? her? her?
What would you have done if the drug What would you have done if the drug y g y g
was not compatible with was not compatible with
breastfeeding? breastfeeding? breastfeeding? breastfeeding?
33 33
Recommendation Recommendation Recommendation Recommendation
OK to breastfeed while taking OK to breastfeed while taking OK to breastfeed while taking OK to breastfeed while taking
Xybotic Xybotic
Observe for possible adverse effects Observe for possible adverse effects Observe for possible adverse effects Observe for possible adverse effects
in child (diarrhea or possible allergic in child (diarrhea or possible allergic
reaction) reaction) reaction) reaction)
Not necessary, but can avoid Not necessary, but can avoid
b tf di til 2 h ft b tf di til 2 h ft breastfeeding until 2 hours after breastfeeding until 2 hours after
taking drug taking drug
34 34
What Else Could You Do? What Else Could You Do? What Else Could You Do? What Else Could You Do?
Look for breastfeeding Look for breastfeeding Look for breastfeeding Look for breastfeeding
compatible alternative in the compatible alternative in the
d t ( H l d t ( H l same drug category (e.g., Hale same drug category (e.g., Hale
and LactMed suggest and LactMed suggest
alternatives) alternatives)
If no alternative drug, go If no alternative drug, go If no alternative drug, go If no alternative drug, go
through the Stepwise Approach through the Stepwise Approach
35 35
Photo Courtesy of NIH Photo Courtesy of NIH 36 36
CONSIDERATIONS: CONSIDERATIONS:
P i i D P i i D Prescription Drugs Prescription Drugs
Analgesics Analgesics gg
Nonnarcotic Nonnarcotic
Narcotic Narcotic
General and Epidural General and Epidural
Anti Anti--Infectives Infectives
Antihistamines/ Antihistamines/
Decongestants Decongestants Decongestants Decongestants
Bronchodilators Bronchodilators
Corticosteroids Corticosteroids
Antihypertensives Antihypertensives
Cardiac Drugs Cardiac Drugs
37 37
CONSIDERATIONS: CONSIDERATIONS:
Prescription Drugs Prescription Drugs
Anticoagulants Anticoagulants gg
Diuretics Diuretics
Antidiabetics Antidiabetics
Th id/A ti Th id/A ti Th id D Th id D Thyroid/Anti Thyroid/Anti--Thyroid Drugs Thyroid Drugs
Hormone Contraceptives Hormone Contraceptives
Gastrointestinal Drugs Gastrointestinal Drugs Gastrointestinal Drugs Gastrointestinal Drugs
Psychotherapeutic Drugs Psychotherapeutic Drugs
Benzodiazepines Benzodiazepines
Antiepileptics Antiepileptics
Radiopharmaceuticals Radiopharmaceuticals
Miscellaneous Drugs Miscellaneous Drugs
38 38
Miscellaneous Drugs Miscellaneous Drugs
SSRIs SSRIs SSRIs SSRIs
11 Sertraline (Zoloft) Sertraline (Zoloft) 11. Sertraline (Zoloft) . Sertraline (Zoloft)
2. Escitalopram (Lexapro) 2. Escitalopram (Lexapro)
2 Paroxetine (Paxil) 2 Paroxetine (Paxil) 2. Paroxetine (Paxil) 2. Paroxetine (Paxil)
4. Venlafaxine (Effexor) 4. Venlafaxine (Effexor)
5 Fluvoxamine (Luvox) 5 Fluvoxamine (Luvox) 5. Fluvoxamine (Luvox) 5. Fluvoxamine (Luvox)
6. Citalopram (Celexa) 6. Citalopram (Celexa)
7 Fl ti (P ) 7 Fl ti (P ) 7. Fluoxetine (Prozac) 7. Fluoxetine (Prozac)
39 39
ADVERSE EFFECTS ADVERSE EFFECTS
(Overall Rate: 1%) (Overall Rate: 1%)
Psychotherapeutics (Antidepressants, Sedatives, Psychotherapeutics (Antidepressants, Sedatives,
Antipsychotics): 31% Antipsychotics): 31%
Antimicrobials: 17% Antimicrobials: 17%
Anticonvulsants: 16% Anticonvulsants: 16% Anticonvulsants: 16% Anticonvulsants: 16%
Analgesics (NSAIDs, Opioids): 12% Analgesics (NSAIDs, Opioids): 12%
Hormonal Drugs: 5% Hormonal Drugs: 5%
Iodides: 5% Iodides: 5% Iodides: 5% Iodides: 5%
Cardiovascular Drugs: 4% Cardiovascular Drugs: 4%
GIT Drugs: 2% GIT Drugs: 2%
Antihistamines: 2% Antihistamines: 2%
Chemotherapeutics: 2% Chemotherapeutics: 2%
40 40
ADVERSE EFFECTS ADVERSE EFFECTS ADVERSE EFFECTS ADVERSE EFFECTS
Psychotherapeutics (Antidepressants, Sedatives, Psychotherapeutics (Antidepressants, Sedatives,
Antipsychotics): Drowsiness Antipsychotics): Drowsiness
Antimicrobials: Diarrhea Antimicrobials: Diarrhea
Anticonvulsants: Drowsiness, sedation, poor feeding Anticonvulsants: Drowsiness, sedation, poor feeding Anticonvulsants: Drowsiness, sedation, poor feeding Anticonvulsants: Drowsiness, sedation, poor feeding
Analgesics (NSAIDs, Opioids): Drowsiness, sedation Analgesics (NSAIDs, Opioids): Drowsiness, sedation
Hormonal Drugs: Decreased milk supply, volume, Hormonal Drugs: Decreased milk supply, volume,
quantity quantity quantity quantity
Iodides: Thyroid suppression Iodides: Thyroid suppression
Cardiovascular Drugs: Weakness, hypotension, Cardiovascular Drugs: Weakness, hypotension,
bradycardia bradycardia bradycardia bradycardia
GIT Drugs: GIT upset GIT Drugs: GIT upset
Antihistamines: Irritability, drowsiness Antihistamines: Irritability, drowsiness
41 41
Chemotherapeutics: Toxic effects of treatment Chemotherapeutics: Toxic effects of treatment
ADVERSE EFFECTS ADVERSE EFFECTS
(R f ) (R f ) (References) (References)
Anderson PO, Pochop SL, Manoguerra AS: Anderson PO, Pochop SL, Manoguerra AS: , p , g , p , g
Adverse drug reactions in breastfed infants: less Adverse drug reactions in breastfed infants: less
than imagined. Clin Ped: 42 (4), 325 than imagined. Clin Ped: 42 (4), 325--40: 2003 40: 2003
I S Bl j h A S h M l I S Bl j h A S h M l Ito S, Blajchman A, Stephenson M, et al: Ito S, Blajchman A, Stephenson M, et al:
Prospective follow Prospective follow--up of adverse reactions in up of adverse reactions in
breast breast--fed infants exposed to maternal fed infants exposed to maternal breast breast fed infants exposed to maternal fed infants exposed to maternal
medication. Am J Obstet Gynecol: 168 (5), medication. Am J Obstet Gynecol: 168 (5),
1393 1393--9: 1993 9: 1993
42 42
Codeine Rapid Metabolizers Codeine Rapid Metabolizers Codeine Rapid Metabolizers Codeine Rapid Metabolizers
13 13--day breastfed baby dies from day breastfed baby dies from 13 13 day breastfed baby dies from day breastfed baby dies from
morphine overdose in breast milk in morphine overdose in breast milk in
mother taking codeine mother taking codeine mother taking codeine mother taking codeine
How did that ever happen? How did that ever happen?
43 43
ABMClinical Protocol #15 ABMClinical Protocol #15 ABM Clinical Protocol #15 ABM Clinical Protocol #15
Academy of Breastfeeding Medicine Clinical Academy of Breastfeeding Medicine Clinical
Protocol #15: Protocol #15: Protocol #15: Protocol #15:
Analgesia and Anesthesia for the Breastfeeding Analgesia and Anesthesia for the Breastfeeding
Mother Mother
Anne Montgomery, Thomas W. Hale, and The Anne Montgomery, Thomas W. Hale, and The
Academy of Breastfeeding Medicine Protocol Academy of Breastfeeding Medicine Protocol
Committee Committee Committee Committee
Reprint Requests: abm@bfmed.org Reprint Requests: abm@bfmed.org
http://www.bfmed.org/Resources/ http://www.bfmed.org/Resources/ p // g/ / p // g/ /
Protocols.aspx Protocols.aspx
44 44
CONSIDERATIONS: CONSIDERATIONS:
OTC M di i OTC M di i OTC Medications OTC Medications
Analgesics Analgesics Anti Anti--Diarrheal Preparations Diarrheal Preparations Analgesics Analgesics
Cough, Cold, and Allergy Cough, Cold, and Allergy
Preparations Preparations
C h d C ld L C h d C ld L
Anti Anti Diarrheal Preparations Diarrheal Preparations
Nausea and Vomiting / Motion Nausea and Vomiting / Motion
Sickness Preparations Sickness Preparations
Hemorrhoidal Preparations Hemorrhoidal Preparations
Cough and Cold Lozenges Cough and Cold Lozenges
and Sprays and Sprays
Nasal Preparations Nasal Preparations
Hemorrhoidal Preparations Hemorrhoidal Preparations
Sleep Preparations Sleep Preparations
Stimulants Stimulants
A tit S t P d t A tit S t P d t
pp
Asthma Preparations Asthma Preparations
Antacids and Digestive Aids Antacids and Digestive Aids
Appetite Suppressant Products Appetite Suppressant Products
Insulin Preparations Insulin Preparations
Artificial Sweeteners Artificial Sweeteners
Laxatives / Stool Softeners Laxatives / Stool Softeners
Miscellaneous OTCs Miscellaneous OTCs
45 45
OTC OTC
BREASTFEEDING COUNSELING BREASTFEEDING COUNSELING BREASTFEEDING COUNSELING BREASTFEEDING COUNSELING
GUIDELINES GUIDELINES
Avoid taking OTC medications for which safer products Avoid taking OTC medications for which safer products g p g p
are available. are available.
Avoid taking OTC medications for which little Avoid taking OTC medications for which little
breastfeeding information is available. breastfeeding information is available. breastfeeding information is available. breastfeeding information is available.
Avoid taking combination OTCs, which are those with Avoid taking combination OTCs, which are those with
multiple ingredients (it is better for the mother to take an multiple ingredients (it is better for the mother to take an
OTC that has the one or two specific ingredients that will OTC that has the one or two specific ingredients that will OTC that has the one or two specific ingredients that will OTC that has the one or two specific ingredients that will
treat her specific condition; there is no need for the treat her specific condition; there is no need for the
mothers or nurslings to be exposed to unnecessary mothers or nurslings to be exposed to unnecessary
ingredients) ingredients) ingredients). ingredients).
46 46
OTC OTC
BREASTFEEDING COUNSELING BREASTFEEDING COUNSELING BREASTFEEDING COUNSELING BREASTFEEDING COUNSELING
GUIDELINES GUIDELINES
Avoid taking extra strength forms of OTC medications Avoid taking extra strength forms of OTC medications g g g g
(there is no need for the nursling to be exposed to extra (there is no need for the nursling to be exposed to extra
amounts of a drug when it is not needed). amounts of a drug when it is not needed).
Avoid taking long Avoid taking long--acting OTC medications (there is no acting OTC medications (there is no Avoid taking long Avoid taking long acting OTC medications (there is no acting OTC medications (there is no
need for the nursling to be exposed to a drug for a longer need for the nursling to be exposed to a drug for a longer
period of time, especially if an adverse reaction is period of time, especially if an adverse reaction is
possible in the nursling) possible in the nursling) possible in the nursling). possible in the nursling).
The mother should know about possible side effects that The mother should know about possible side effects that
might occur in her nursling, as well as herself. might occur in her nursling, as well as herself.
If ibl ith i ti d th th h ld If ibl ith i ti d th th h ld If possible, as with prescription drugs, the mother should If possible, as with prescription drugs, the mother should
use a nondrug approach for treating her symptoms. use a nondrug approach for treating her symptoms.
47 47
CONSIDERATIONS: CONSIDERATIONS:
H b l (M j G l ) H b l (M j G l ) Herbals (Major Galactogogues) Herbals (Major Galactogogues)
Chaste Tree Chaste Tree Chaste Tree Chaste Tree
Fennel Fennel
Fenugreek Fenugreek Fenugreek Fenugreek
Garlic Garlic
Goat's Rue Goat's Rue
Milk Thistle / Blessed Thistle Milk Thistle / Blessed Thistle
48 48
CONSIDERATIONS: CONSIDERATIONS:
H b l (Mi G l ) H b l (Mi G l ) Herbals (Minor Galactogogues) Herbals (Minor Galactogogues)
Anise Anise Marshmallow Marshmallow Anise Anise
Borage Borage
Alfalfa Alfalfa
Marshmallow Marshmallow
Nettle Nettle
Hops Hops Alfalfa Alfalfa
Caraway Caraway
Coriander Coriander
Hops Hops
Oat Straw Oat Straw
Red Clover Red Clover Coriander Coriander
Dandelion Dandelion
Dill Dill
Red Clover Red Clover
Red Raspberry Red Raspberry
Vervain Vervain Dill Dill Vervain Vervain
49 49
CONSIDERATIONS: CONSIDERATIONS:
H b l H b l Herbals Herbals
Analgesics Analgesics
Bugleweed, Comfrey Bugleweed, Comfrey
Headache (Migraine) Agents Headache (Migraine) Agents
Feverfew Feverfew Feverfew Feverfew
Anti Anti--Anxiety Agents Anxiety Agents
Indian Snakeroot, Kava Kava, Passionflower, Indian Snakeroot, Kava Kava, Passionflower,
St J ohns Wort Valerian St J ohns Wort Valerian St. J ohns Wort, Valerian St. J ohns Wort, Valerian
Stimulants Stimulants
Ginseng Root, Siberian Ginseng, Ginkgo Biloba, Ginseng Root, Siberian Ginseng, Ginkgo Biloba,
A li R t / D Q i A li R t / D Q i Angelica Root / Dong Quai Angelica Root / Dong Quai
Sleep Preparations Sleep Preparations
Melatonin Melatonin
50 50
CONSIDERATIONS: CONSIDERATIONS:
H b l H b l Herbals Herbals
Cough, Cold, and Allergy Products Cough, Cold, and Allergy Products
Coltsfoot, Echinacea, Elder Flower Coltsfoot, Echinacea, Elder Flower
Gastrointestinal Agents Gastrointestinal Agents Gastrointestinal Agents Gastrointestinal Agents
Aloe, Buckthorn, Cascara Sagrada, Chamomile, Aloe, Buckthorn, Cascara Sagrada, Chamomile,
Flaxseed, Licorice, Psyllium Seed, Rhubarb, Senna Flaxseed, Licorice, Psyllium Seed, Rhubarb, Senna
Nausea and Vomiting Preparations Nausea and Vomiting Preparations Nausea and Vomiting Preparations Nausea and Vomiting Preparations
Ginger Ginger
Lipid Lowering Agents Lipid Lowering Agents
S L ithi S L ithi Soy Lecithin Soy Lecithin
Urinary Tract Preparations Urinary Tract Preparations
Goldenrod, Petasites, Uva Ursi Goldenrod, Petasites, Uva Ursi
51 51
CONSIDERATIONS: CONSIDERATIONS:
R i l D R i l D Recreational Drugs Recreational Drugs
Amphetamine / Methylphenidate Amphetamine / Methylphenidate p yp p yp
Marijuana Marijuana
Cocaine Cocaine Cocaine Cocaine
Phencyclidine Phencyclidine
Narcotics Narcotics
Caffeine Caffeine
Alcohol Alcohol
Nicotine Nicotine
52 52
Nicotine Nicotine
RECREATIONAL DRUGS RECREATIONAL DRUGS RECREATIONAL DRUGS RECREATIONAL DRUGS
Fromboth a philosophical and scientific Fromboth a philosophical and scientific From both a philosophical and scientific From both a philosophical and scientific
viewpoint, recreational drugs of abuse viewpoint, recreational drugs of abuse
should be should be contraindicated during contraindicated during should be should be contraindicated during contraindicated during
breastfeeding breastfeeding as they are hazardous, not as they are hazardous, not
only to the nursling but to the mother as only to the nursling but to the mother as only to the nursling, but to the mother as only to the nursling, but to the mother as
well. well.
53 53
FINAL CONSIDERATIONS FINAL CONSIDERATIONS
Only essential drugs should be taken by the
i th Sh h ld b nursing mother. She should be
knowledgeable of and be encouraged to report
any adverse effects any adverse effects
For newer drugs, sufficient information is often g ,
unavailable. If information is available, it
requires careful interpretation and evaluation
Recognizing the benefits of continuing to
nurse in most cases drugs that have safe
54 54
nurse, in most cases, drugs that have safe
therapeutic levels can be given
Courtesy of NIH Courtesy of NIH 55 55
J APhA Article J APhA Article J APhA Article J APhA Article
Nice FJ Luo AC: Medications and Nice FJ Luo AC: Medications and Nice FJ, Luo AC: Medications and Nice FJ, Luo AC: Medications and
Breast Breast- -feeding: Current Concepts. feeding: Current Concepts.
Journal of the American Pharmacists Journal of the American Pharmacists Journal of the American Pharmacists Journal of the American Pharmacists
Association. 52: 86 Association. 52: 86- -94 94
(January/February) 2012 (January/February) 2012 (January/February) 2012. (January/February) 2012.
56 56
PUBLICATIONS PUBLICATIONS PUBLICATIONS PUBLICATIONS
Nice FJ: Common Herbs and Foods Nice FJ: Common Herbs and Foods
Used as Galactogogues ICAN: Used as Galactogogues ICAN: Used as Galactogogues. ICAN: Used as Galactogogues. ICAN:
Infant, Child, & Adolescent Nutrition, Infant, Child, & Adolescent Nutrition,
3: 129 3: 129 132 (June) 2011 132 (June) 2011 3: 129 3: 129--132 (June) 2011. 132 (June) 2011.
PUBLICATIONS PUBLICATIONS PUBLICATIONS PUBLICATIONS
Nice FJ, DeEugenio D, DiMino TA, Freeny IC, Nice FJ, DeEugenio D, DiMino TA, Freeny IC, , g , , y , , g , , y ,
Rovnack MB, and Gromelski JS: Rovnack MB, and Gromelski JS:
Medications and Breast Medications and Breast- -Feeding: A Guide Feeding: A Guide
for Pharmacists, Pharmacy Technicians, and for Pharmacists, Pharmacy Technicians, and
Other Healthcare Professionals, Other Healthcare Professionals, Part I Part I. .
J l f Ph T h l J l f Ph T h l 20 17 20 17 27 27 Journal of Pharmacy Technology Journal of Pharmacy Technology, 20: 17 , 20: 17--27 27
(January/February) 2004. (January/February) 2004.
58 58
PUBLICATIONS PUBLICATIONS PUBLICATIONS PUBLICATIONS
NNice FJ DeEugenio D DiMino TA Freeny ice FJ DeEugenio D DiMino TA Freeny NNice FJ, DeEugenio D, DiMino TA, Freeny ice FJ, DeEugenio D, DiMino TA, Freeny
IC, Rovnack MB, and Gromelski JS: IC, Rovnack MB, and Gromelski JS:
Medications and Breast Medications and Breast--Feeding: A Guide Feeding: A Guide Medications and Breast Medications and Breast Feeding: A Guide Feeding: A Guide
for Pharmacists, Pharmacy Technicians, and for Pharmacists, Pharmacy Technicians, and
Other Healthcare Professionals, Other Healthcare Professionals, Part II Part II. .
Journal of Pharmacy Technology Journal of Pharmacy Technology, 20: 85 , 20: 85- -95 95
(March/April) 2004 (March/April) 2004..
59 59
PUBLICATIONS PUBLICATIONS PUBLICATIONS PUBLICATIONS
Nice FJ, DeEugenio D, DiMino TA, Freeny IC, Nice FJ, DeEugenio D, DiMino TA, Freeny IC, Nice FJ, DeEugenio D, DiMino TA, Freeny IC, Nice FJ, DeEugenio D, DiMino TA, Freeny IC,
Rovnack MB, and Gromelski JS: Rovnack MB, and Gromelski JS:
Medications and Breast Medications and Breast- -Feeding: A Guide for Feeding: A Guide for gg
Pharmacists, Pharmacy Technicians, and Pharmacists, Pharmacy Technicians, and
Other Healthcare Professionals, Other Healthcare Professionals, Part III Part III. .
Journal of Pharmacy Technology Journal of Pharmacy Technology, 20: 165 , 20: 165- -177 177
(May/June) 2004. (May/June) 2004.
60 60
PUBLICATIONS PUBLICATIONS PUBLICATIONS PUBLICATIONS
Nice FJ: Over Nice FJ: Over- -the the--Counter Medication Use During Counter Medication Use During
Breastfeeding Breastfeeding Pharmacy Times Pharmacy Times 67:46 48 67:46 48--49 49 Breastfeeding. Breastfeeding. Pharmacy Times Pharmacy Times, 67:46,48 , 67:46,48 49 49
(January) 2001. (January) 2001.
Nice FJ Snyder JL and Kotansky BC: Breastfeeding Nice FJ Snyder JL and Kotansky BC: Breastfeeding Nice FJ, Snyder JL, and Kotansky BC: Breastfeeding Nice FJ, Snyder JL, and Kotansky BC: Breastfeeding
and Over and Over- -the the--Counter Medications. Counter Medications. Journal of Journal of
Human Lactation Human Lactation, 16: 319 , 16: 319- -331 (November) 2000. 331 (November) 2000.
Nice FJ, Coghlan RJ, and Birmingham BT: Herbals Nice FJ, Coghlan RJ, and Birmingham BT: Herbals
and Breastfeeding: Which Herbals Are Safe To Take and Breastfeeding: Which Herbals Are Safe To Take
While Breastfeeding? While Breastfeeding? Birth Issues Journal Birth Issues Journal 9:77 9:77--84 84 While Breastfeeding? While Breastfeeding? Birth Issues Journal Birth Issues Journal, 9:77 , 9:77 84 84
(September/October) 2000. (September/October) 2000.
61 61
PUBLICATIONS PUBLICATIONS PUBLICATIONS PUBLICATIONS
Nice FJ, Coghlan RJ, and Birmingham BT: Herbals Nice FJ, Coghlan RJ, and Birmingham BT: Herbals Nice FJ, Coghlan RJ, and Birmingham BT: Herbals Nice FJ, Coghlan RJ, and Birmingham BT: Herbals
and Breastfeeding. and Breastfeeding. U.S. Pharmacist U.S. Pharmacist, 25: 28, 31 , 25: 28, 31- -
32, 24, 41 32, 24, 41- -42, 45 42, 45- -46 (September) 2000. 46 (September) 2000.
Nice FJ, Pincock L, and Nguyen ME: Medications Nice FJ, Pincock L, and Nguyen ME: Medications
and Breastfeeding: What Pharmacists Can Tell and Breastfeeding: What Pharmacists Can Tell and Breastfeeding: What Pharmacists Can Tell and Breastfeeding: What Pharmacists Can Tell
Nursing Mothers. Nursing Mothers. Pharmacy Times Pharmacy Times, 65: 52, 55 , 65: 52, 55- -
58, 61 58, 61- -62, 64 62, 64- -66, 68, 70, 72 (September) 1999. 66, 68, 70, 72 (September) 1999.
62 62
Thank you for your participation Thank you for your participation Thank you for your participation Thank you for your participation
63 63