Preface
Introduction
It’s now well known that human milk is the best nutrition for infants. The benefits are simply enormous and supported by a world of excellent literature. Further, it is becoming more and more apparent that breastfeeding has long-lasting health benefits for the mom. However, the use of medications in breastfeeding mothers is often controversial and is steeped with misinformation in the healthcare field. This book has for many years been the primary source for drug information and in breastfeeding mothers. The truth is, most drugs simply don’t enter milk in levels that are hazardous to a breastfed infant. The problem, however, is determining which drugs are safe and which are hazardous.
Because so few clinicians understand lactational pharmacology, the number of women who are advised to discontinue breastfeeding in order to take a medication is still far too high. Fortunately, many mothers are now becoming aware of the enormous benefits of breastfeeding and simply refuse to follow some of the advice given by their healthcare professionals. They seek out the information on their own and invariably find this book or my websites.
Because almost all mothers will ingest medications during the early neonatal period, it is not surprising that one of the most common questions encountered in pediatrics concerns the use of various drugs in the breastfeeding mother. Unfortunately, most healthcare professionals simply review the package insert or advise the mother not to breastfeed without having done a thorough study of the literature to find the true answer. Discontinuing breastfeeding is often the wrong decision, and most mothers could easily continue to breastfeed and take the medication without risk to the infant. Even the
It is generally accepted that all medications transfer into human milk to some degree, although it is almost always quite low. Only rarely does the amount transferred into milk produce clinically relevant doses in the infant. Ultimately, it is the clinician’s responsibility to review the research and make a clear decision as to whether the mother should continue to breastfeed.
Attain high concentrations in maternal plasma
Are low in molecular weight (<500 Da)
Are low in protein binding
Pass into the brain easily
However, once medications transfer into human milk, other kinetic factors are involved. One of the most important is the oral bioavailability of the medication to the infant. Numerous medications are either destroyed in the infant’s gut, fail to be absorbed through the gut wall, or are rapidly picked up by the liver. Once in the liver, they are either metabolized or stored, but often never reach the mother’s plasma.
Drugs normally enter milk by passive diffusion, driven by equilibrium forces between the maternal plasma compartment and the maternal milk compartment. They pass from the maternal plasma through capillaries into the lactocytes lining the alveolus. Medications must generally pass through both bilayer lipid membranes of the alveolar cell to penetrate milk; although early on, they may pass between the alveolar cells (first 72 hours postpartum). During the first three days postpartum, large gaps between the alveolar cells exist. These gaps permit enhanced access into the milk for most drugs, many immunoglobulins, maternal living cells (lymphocytes, leukocytes, macrophages), and other maternal proteins. By the end of the first week, the alveolar cells swell under the influence of prolactin and subsequently close the intracellular gaps thus reducing the transcellular entry of most maternal drugs, proteins, and other substances into the milk compartment. While it is generally agreed that medications penetrate into milk at higher levels during the colostral period, nevertheless, the absolute dose transferred during the colostrum period is still low due to the minimal volume of colostrum (30-100 mL/day) for the first few days postpartum.
In most instances, the most important determinant of drug penetration into milk is the mother’s plasma level. Almost without exception, as the level of the medication in the mother’s plasma rises, the concentration in milk increases as well. Drugs enter and exit milk as a function of the mother’s plasma level. As soon as the maternal plasma level of a medication begins to fall, equilibrium forces drive the medication out of the milk compartment back into the maternal plasma for elimination. Maternal plasma levels are almost always directly related to the maternal drug dose. Higher doses produce higher plasma levels, and therefore higher milk levels. It is always recommended to use drug doses evaluated in lactation studies. We often see doses up to five times higher than those researched, limiting the generalizability of the findings.
In some instances, drugs may be trapped in milk (ion trapping) due to the lower pH of human milk (7.2). Drugs with a high pKa may become trapped in the milk compartment due to ion trapping. This is important in weakly basic drugs, such as the barbiturates (drugs with high pKa).
There are some known cellular pumping systems that actively pump drugs into milk. The most important is iodine. The iodine pump is the same as found in everyone’s thyroid gland. Its purpose is to make sure the infant receives iodine to maintain thyroxine production.
The iodides, such as 131I or any “ionic” form of iodine, concentrate in milk due to this pump. Thus iodides, particularly radioactive ones, should be avoided as their milk concentrations are exceedingly high. Two other physicochemical factors are important in evaluating drugs in breastfeeding mothers—the degree of protein binding and lipid solubility. Drugs that are very lipid soluble penetrate into milk in higher concentrations almost without exception. Of particular interest are the drugs that are active in the central nervous system (
Once a drug has entered the mother’s milk and has been ingested by the infant, it must traverse through the infant’s
One of the more popular methods for estimating risk to the infant is the Relative Infant Dose (
Avoid using medications that are not necessary. Herbal drugs, high-dose vitamins, unusual supplements, iodine supplements, zinc supplements, etc. that are simply not necessary should be avoided.
If the Relative Infant Dose is less than 10%, most medications are considered relatively safe to use, but again this is dependent on the type of drug taken.
Choose drugs for which we have published data, at studied doses, rather than those recently introduced.
Evaluate the infant for risks. Be more cautious with premature infants or neonates.
Medication used in the first three to four days generally produce subclinical levels in the infant due to the limited volume of milk.
Recommend that mothers with symptoms of depression or other mental disorders seek treatment. Most of the medications used to treat these syndromes are safe. Remember, healthy moms make healthy babies.
Most drugs are quite safe in breastfeeding mothers, while the hazards of using formula are well known and documented. Use donor human milk when the drug is potentially dangerous.
With some medications, discontinuing breastfeeding for some hours/days may be required, particularly with radioactive compounds, and anticancer drugs. If the drug is hazardous to you, it is probably hazardous to your infant.
Choose drugs with short half-lives, high protein binding, low oral bioavailability, or high molecular weight.
Lastly, it is very important to always evaluate the infant’s ability to handle small amounts of medications. Some infants, such as premature or unstable infants, may not be suitable candidates for certain medications. But remember that early postpartum (and in late stage lactation), the amount of milk produced (30-100 mL/day) is so low that the clinical dose of drug transferred is often low, so even premature neonates would receive only a limited amount from the milk.
Inquire about the infant—always inquire as to the infant’s age, size, and stability. This is perhaps the most important criterion to be evaluated prior to using the medication.
Infant age—premature and newborn infants are at somewhat greater risk. Over half of reported adverse events happen within the first four weeks of age. Only 1 in 5 reports occur after the first 8 weeks. Older infant are at somewhat lower risk due to high metabolic capacity. Infants breastfeeding once or twice a day are at very low risk.
Infant stability—unstable infants with poor
GI stability may be at increased risk from certain medications.Pediatric Approved Drugs—generally are less hazardous if long-term history of safety is recognized.
Dose vs Age—the age of an infant is critical. Use medications cautiously in premature infants. Older, mature infants can metabolize and clear medications much easier. Remember the dose of the drug the infant receives is dependent on the milk supply. In mothers in late stage lactation (>1 year), milk production is often low, so the dose of drug delivered is low as well.
Drugs that alter milk production may profoundly affect infant growth and development—avoid medications that may alter the mother’s milk production. These include estrogens, ergot alkaloids, and other drugs.
General Suggestions for the Clinician
Determine if the drug is absorbed from the
Review the Relative Infant Dose (
Be cautious of drugs (or their active metabolites) that have long pediatric half-lives as they can continually build up in the infant’s plasma over time. The barbiturates, benzodiazepines, and meperidine are classic examples where higher levels in the infant can and do occasionally occur. Interestingly, the
If you are provided a choice, choose drugs that have higher protein binding because they are generally sequestered in the maternal circulation and do not transfer readily into the milk compartment or the infant. Remember, it’s the free drug that transfers into the milk compartment. Without doubt, the most important parameter that determines drug penetration into milk is plasma protein binding. Choose drugs with high protein binding.
Although not always true, we have generally found centrally active drugs (anticonvulsants, antidepressants, antipsychotic) frequently penetrate milk in higher (not necessarily “high”) levels simply due to their physicochemistry. If the drug in question produces sedation, depression, or other neuroleptic effects in the mother, it may produce similar effects in the infant. Thus, with
For radioactive compounds, we have gathered much of the published data in this field into several tables. The Nuclear Regulatory Commission recommendations are quite good, but they differ from some published data. They can be copied and provided to your radiologist. They are available from the Nuclear Regulatory Commission’s web page address in the appendix. With radioisotopes, we recommend you routinely call the InfantRisk Center for advice. Some are quite dangerous.
Use the Relative Infant Dose. In general, a Relative Infant Dose of <10% is considered safe, and its use is becoming increasingly popular by numerous investigators. But this depends on the drug. With risky anticancer drugs, a much lower
Most importantly, it is rare that a breastfeeding mother needs to discontinue breastfeeding just to take a medication. It is simply not acceptable for the clinician to stop lactation merely because of heightened anxiety or ignorance on their part. The risks of formula feeding are significant and should not be trivialized. Few drugs have documented side effects in breastfed infants, and we know most of these.
The following review of drugs is a thorough review of what has been published and what we presently know about the use of medications in breastfeeding mothers.
The authors make no recommendations as to the safety of these medications during lactation in clinical practice, but only review what is currently published in the scientific literature. Individual use of medications must be left up to the judgement of the physician, the patient, and other healthcare consultants.