The document provides information on counseling principles for medication use during breastfeeding. It discusses several key points:
- Nearly all drugs pass into human milk, usually in small amounts less than 1% of the maternal dose. Very few drugs are contraindicated.
- Factors like a drug's protein binding, lipid solubility, molecular weight, and oral bioavailability determine how much passes into breastmilk. Short-acting drugs with high protein binding and low lipid solubility pass in smaller amounts.
- When counseling patients, healthcare providers should evaluate if medication is truly needed, recommend taking it after nursing, and choose drugs with known low risk to infants based on existing data. Short-term use or local administration can
4. Healthy People 2010 Goals
• Increase to at least 75% the proportion of mothers
breastfeeding upon discharge and 50% still breastfeeding
when the infant is 6 months of age.
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10
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50
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1970 1995 1998 2010
Goal
Discharge
6 Months
6. Obstacles to Initiating and Continuing Breastfeeding
• Physician apathy and misinformation
• Insufficient pre-natal breastfeeding education
• Distribution and promotion of infant formula
• Disruptive hospital policies
• Inappropriate interruptions of breastfeeding
• Early hospital discharge
• Lack of social support
7. Role of the Physician
• Establish positive attitudes in pregnancy
• Address medical issues/ physical obstacles
• Encourage nursing immediately after delivery
• Provide post-partum support
• Explain nutritional needs
• Assess substance use
• Discuss employment concerns
8. Establish Positive Attitudes
• Endorse and encourage breastfeeding because
it is best for mother and baby.
• Ask about previous experience
• Provide positive statements about breastfeeding
• Offer confirmatory words from all office staff
• Distribute appropriate education materials
• Be supportive no matter what the woman plans
9. General Benefits of Breastfeeding
• Maternal-infant bonding
• Inexpensive
• Convenient (no preparation)
• Perfect temperature
• Easily digested
• Immunological protection
• Allergy prophylaxis
10. Breastfeeding Advantages for Mothers
• May delay return of ovulation.
• Loss of pregnancy associated adipose tissue.
• Reduction in postpartum blood loss due to
increased oxytocin levels.
• Reduction in pre-menopausal breast cancer
and reduced risk of ovarian cancer.
• Improved bone remineralization postpartum.
11. Immunological Contents of Breast Milk
• Immunoglobulins
– IgA, IgG, IgM, leukocytes, cytokines
• Host resistance factors
– Complement macrophages, lymphocytes, lactoferrin
• Anti-inflammatory components
– Enzymes:
catalase, histaminase, lysozymes, lactoperoxidase
– Antioxidants: acsorbic acid, alpha-tocopherol
– Prostoglandins
• Interleukin-6
– Stimulates an increase in mononuclear cells in breast
milk.
12. Breastfeeding Advantages for Baby
• Decreased incidence and/or severity of otitis
media, diarrhea, lower respiratory
infections, bacteremia, bacterial
meningitis, botulism, urinary tract infections, and
necrotizing enterocolitis.
• Less hospitalization in first 6 months.
• Possible protective effect against sudden infant death
syndrome, type 1 diabetes, Crohn’s
disease, ulcerative colitis, lymphoma, allergies, and
chronic digestive diseases.
13. Drugs in Breastfeeding
• Healthcare professionals should always encourage
breastfeeding
• Most drugs excreted into breast milk but usually in small
amounts
• Few drugs are absolutely contra-indicated
• Some drugs may increase or decrease milk yield.
14. Background - Mothers
• 90% of women are prescribed a medication in first week
postpartum
• Mothers worry about effect of medication on nursing
infant
• Leads to: non compliance, weaning, avoidance of
breastfeeding
• 50% of mothers more reluctant to take a medication
while nursing than during pregnancy
15. Seven contraindications to breastfeeding (AAP 2
005)
• Mother HIV + (in USA)
• Use of illegal drugs by mother
• Certain medications
• Active, untreated TB in mother
• Galactosemia in baby
• Mother HTLV +
• Herpes on breast
16. How to decide if a medication
or drug is ok?
• Pharmacokinetic factors
• Factors which govern drug transfer across membranes
into breast milk as well as the metabolism of the drug in
mother and infant
21. Protein binding
• Medications circulate in maternal circulation bound or
unbound to albumin
• Only unbound drug gets into maternal milk
• Definition of good protein binding = > 90%
23. Lipid solubility
• Drugs that are very lipid soluble penetrate into breast
milk in higher concentration
• Drugs that are active in the CNS are drugs with high lipid
solubility
24. Half life
Short half life drugs
• Alcohol 24 min
• Keflex 50 min
• Ibuprofen 120 min
• General anesthesia
Long half life drugs
• Prozac 216 hours
28. Oral bioavailability
• Low bioavailability may be due to
– Reduced absorption in GI tract
– Poor GI stability due to acidity
– High first-pass uptake by liver
30. Drug
Maternal gut and liver
Maternal plasma
Infant gut
Infant plasma
Oral bioavailability varies
High (>90%) Low (<50%)
Acetaminopen Acyclovir Lorazepam
Azithromycin
Metronidazole Budesonide
Minoxidil Sulfasalazine
Dilution of all drugs leads to low
concentrations in mother’s plasma
Only drugs are not protein-bound
can pass into milk
Drug protein binding
High Low
Bepridil >99% Bisoprolol 30%
Diazepam 99% Cyclophosphamide 13%
Diclofenac >99% Ranitidine 15%
Propranolol 90% Primidone <20%
Oral bioavailiability varies
Usually very low levels
(often undetectable)
Route of drugs from mother to baby via breastmilk
32. Choice of Drug
• Short acting
• Highly protein bound
• Low lipid solubility
• High molecular weight
• No active metabolites
• Low oral bioavailability
• Route of administration
33. Drugs in Lactation – Factors to consider
• Avoid unnecessary drug use and limit use of OTC products
• Assess the benefit/risk ratio for both mother and infant
• Avoid use of drugs known to cause serious toxicity in adults or
children
• Drugs licensed for use in infants do not generally pose a hazard
• Neonates (esp premature infants) are at greater risk from exposure
to drugs via breast milk
• Route of administration (minimum amount of drug to the infant)
• Avoid long-acting preparations
• Monitor Infants exposed to drugs via breast milk for unusual
signs/symptoms
• Avoid new drugs if possible
34. Drug transfer into the breast milk
• Maternal factor
– Dose and duration of therapy
– Route of administration
– Drug pharmacokinetics
• Infant factor
– Infant’s ability to absorb, metabolize, and excrete the drug
– Gestational age of infant and its postnatal age
35. Way to minimize infant drug exposure
• Avoid feeding the infant at the time of peak concentration of the drug
in milk.
• Withhold breastfeeding temporarily if the drug is only used for a
short duration.
• Choose drugs for the mother that have known and established
information about their pharmacokinetics and toxicity and have low
concentrations in breast milk and low relative infant dose
• Choose drugs that can be locally rather than systemically
administered
• In case of long-acting drugs, time the drug administration to a once-
a-day dose just before the infant’s longest sleep period to lessen
exposure.
36. Evaluation of the infant
• Infant age
– Premature and newborn infants are at somewhat greater risk
• Infant stability
– Unstable infants with poor GI stability may increase the risk of
using medications
• Pediatric approved drugs
– Generally are less hazardous if long-term history of safety is
recognized
• Dose
– In a premature infant various doses may be more risky than in a
1 year old healthy infant
• Drugs that alter milk production
– May be much more risky during neonatal period than much later
37. Summary
• Nearly all drugs pass into human milk
• Almost all medication appears in small amounts, usually less than
1% of the maternal dose
• Very few drugs are contraindicated for nursing mothers
38. LACTATION RISK CATEGORY
BY THOMAS W HALE
• L1 safest
• L2 safer
• L3 moderately safe
• L4 possibly hazardous
• L5 contraindicated
39. DRUG CLASSIFICATION BY AAP
• Cytotoxic drugs
• Drugs of abuse for which adverse effects on the infant
• Radioactive compounds that require temporary cessation of
breastfeeding
• Drugs for which the effect on nursing infants in unknown but may be
concern
• Drugs that have been associated with significant effects on some
nursing infants and should be given to nursing mothers with caution
• Maternal medication usually compatible with breastfeeding
40. 상담 시 주지 사항 및 상담내용
• 약을 꼭 복용해야 하는지 평가한다.
• 젖을 빨리고 난 다음 약을 복용한다.
• 약물을 단기간 사용 할 경우에는 수유를 잠시 멈춘다.
• 정확한 정보가 있는 약으로 아이에게 영향이 적은 약을 선택하게 한다.
• 전신적으로 작용하는 약보다는 국소적으로 작용하는 약을 선택하게 한다.
41. Reasons for using the telephone line
in breastfeeding women
Hemorrhoid
CV disease
GI disease
Contraception
Hepatitis B
Respiratory disease
Others
Psychotic disease
Nutrition
Breast problem
Dental disease
Pain
Inflamation
Dermatologic disease
Thyroid disease
12.5%
11%
9.6%
7.4%
44. Drugs to avoid in the newborn and
in infants < 6months of age
• Beta-blocking agents
– Acebutolol
– Atenolol
– Labetalol
– Propranolol
– Sotalol
• Salicylates
• Lithium
• Antineoplastic agents
• Drugs of abuse
45. Cytotoxic drugs that may interfere
with cellular metabolism of the nursing infant
Cyclophosphamide
Cycloserine
Doxorubicin
Methotrexate
46. Drugs of abuse for which adverse effects on the infant
during breastfeeding have been reported
Drug Reported effect or reasons for concern
Amphetamine Irritability, poor sleeping pattern
Cocain Cocaine intoxication: irritability, vomiting, diarrhea,
tremulousness. seizure
Heroin Tremous, restlessness, vomiting, poor feeding
Marijuana Only 1 report in literature; no effect mentioned; very
long half-life for some components
Phencyclidine Potent hallucinogen
48. Anti-anxiety antidepressants antipsychotic Others
Alprazolam
Diazepam
Lorazepam
Midazolam
Perphenazine
Prazepam
Quazepam
Temazepam
Amitryptiline
Amoxapine
Bupropion
Clomipramine
Desipramine
Dothepine
Doxepine
Fluoxetine
Fluvoxamine
Imipramine
Nortriptyline
Paroxetine
Sertraline
Trazodone
Chloropromazine
Chlorprothixene
Clozapine
Haloperidol
Mesoridazine
Trifluoperazine
Amiodarone
Chloramphenicol
Clofazimine
Lamotrigine
metronidazole
Metoclopramide
Tinidazole
Drugs for which the effect on nursing infants is unknown but
may be of concern
AAP Clssification
49. AAP Clssification
Drug Reported effect
Acebutolol Hypotension; bradycardia; tachycardia
5-aminosalicylic acid Diarrhea
Atenolol Cyanosis; bradycardia
Bromocriptin Suppresses lactation; may be hazardous to the mother
Aspirin Metabolic acidosis
Clemastine Drowsiness irritability, refusal to feed, high-pitched cry, neck stiffness
Ergotamine Vomiting, diarrhea, convulsions
Lithium One-third to one-half therapeutic blood concentration in infants
Phenindione Anticoagulant; increased prothrombin and partial thromboplastin time in 1 infant;
not used in united states
Phenobarbital Sedation; infantile spasm after weaning from milk containing phenobarbital
Primidone Sedation feeding problems
Slfasalazine Bloody diarrhea
Drugs that have been association with significant effects on
some nursing infants and should be given to nursing mothers
with caution