DRUGSDRUGS IN IN LACTATIONLACTATION

I.I. Facts about drugs in lactationFacts about drugs in lactation

II.II. Classification of drugs in lactationClassification of drugs in lactation

III.III. Effects of drugs on the Mother & Effects of drugs on the Mother & BabyBaby

IV.IV. Measures to Minimize Effect of Measures to Minimize Effect of Maternal medicationMaternal medication

TopicsTopics

I. FACTS ABOUT DRUGS IN LACTATION

1.1. Most drugs pass through breastmilk.Most drugs pass through breastmilk.

2.2. 1% less of maternal dose appear in 1% less of maternal dose appear in breastmilk.breastmilk.

3.3. Few drugs are contraindicated.Few drugs are contraindicated.

4.4. Some drugs cause side effects on Some drugs cause side effects on the baby.the baby.

5.5. Baby’s exposure to a drug can be Baby’s exposure to a drug can be minimized.minimized.

II. Classification of Drugs for II. Classification of Drugs for BreastfeedingBreastfeeding

(As to Recommendation during (As to Recommendation during Lactation)Lactation)

ExceptionException

1. Anesthetics1. Anesthetics • SevofluraneSevoflurane• KetamineKetamine• Bupivacaine HclBupivacaine Hcl

2. Antihistaminics2. Antihistaminics • Diphenhydramine Diphenhydramine HclHcl

• LoratadineLoratadine

3. Hypnosedative3. Hypnosedative • MidazolamMidazolam• DiazepamDiazepam

I. COMPATIBLE WITH I. COMPATIBLE WITH

BREASTFEEDINGBREASTFEEDING Safe and No Contraindication Safe and No Contraindication

ExceptionException

4. Muscle 4. Muscle RelaxantRelaxant

• SuxamethoniumSuxamethonium• VecuroniumVecuronium

DantroleneDantrolene

5. Anti-5. Anti-secretory GITsecretory GIT

• CimetidineCimetidine• RanitidineRanitidine

OmeprazoleOmeprazole

MisoprostolMisoprostol

6. Analgesic 6. Analgesic

/Antipyretics/Antipyretics

• ParacetamolParacetamol• AcetaminophenAcetaminophen• NSAid (1NSAid (1stst

generation)generation)

NSAIDNSAID

22ndnd Generation Generation

CelecoxibCelecoxib

compatible

ExceptionException

7. Steroid7. Steroid • Dexamethesone Dexamethesone (single)(single)

• Hydrocortisone Hydrocortisone (single)(single)

compatible

8. Antibacterial8. Antibacterial • ErythromycinErythromycin• AmoxicillinAmoxicillin• Ampicillin Ampicillin • CloxacillinCloxacillin

9. 9. AntihypertensiveAntihypertensive

• Captopril (capoten)Captopril (capoten)• Methyldopa Methyldopa

(Aldomet)(Aldomet)

compatible

ExceptionException

10. Antidysrrhythmia10. Antidysrrhythmia • Lidocaine HclLidocaine Hcl• QuinidineQuinidine

Amioda-Amioda-ronerone

11. Cardiac 11. Cardiac GlycosideGlycoside

• DigitoxinDigitoxin• DigoxinDigoxin

12. Anti-asthma 12. Anti-asthma /Anti-oxytoxic/Anti-oxytoxic

• SalbutamolSalbutamol

13. Antitussives13. Antitussives • Codeine (single Codeine (single dosedose

• Ammonium Ammonium ChlorideChloride

compatible

compatible

ExceptionException

14. Oxytocin14. Oxytocin • Oxytocin (short Oxytocin (short term)term)

15. Diuretics15. Diuretics • MannitolMannitol• SpirinolactoneSpirinolactone

16. Dermatological16. Dermatological

AntifungalAntifungal

• Selenium SulfideSelenium Sulfide

17. Opthalmological17. Opthalmological

AntiglaucomaAntiglaucoma

• AcetazolamideAcetazolamide

18. Cytotoxic Drugs18. Cytotoxic Drugs • Calcium FolinateCalcium Folinate

compatible

ExceptionException

19. Immunologicals19. Immunologicals

ImmunoglobulineImmunoglobuline

VaccineVaccine

• Antitetanus Antitetanus ImmunoglobulineImmunoglobuline

• Diptheria Diptheria AntitoxinAntitoxin

• BCGBCG• MeaslesMeasles

• Smallpox Smallpox vaccinevaccine

20. Vitamins20. Vitamins • Ascorbic in usual Ascorbic in usual dosedose

• ThiamineThiamine

21. Antithyroid21. Antithyroid • LevothyroxineLevothyroxine

compatible

RECOMMENDATION:RECOMMENDATION:

Take the drugs and Take the drugs and

continue to breastfeedcontinue to breastfeed

II. Compatible with Breastfeeding but Monitor Infant for Side Effects

(minor side effects but rare)

Side EffectsSide Effects

1. Anti-1. Anti-cholinergiccholinergic

• AtSO4AtSO4 • Drying of Drying of secretionsecretion

• Increase Increase temperaturetemperature

2. Antiemetics2. Antiemetics • MetoclopramideMetoclopramide

3. Analgesics3. Analgesics • Pethidine in Pethidine in occasional doseoccasional dose

• Morphine in Morphine in occasional doseoccasional dose

Side EffectsSide Effects

4. Anti-TB Drugs4. Anti-TB Drugs • RifampicinRifampicin• StreptomycinStreptomycin• EthambutolEthambutol

JaundiceJaundice

5. Vitamin5. Vitamin • Ascorbic acid Ascorbic acid (large dose(large dose

HemolysisHemolysis

JaundiceJaundice

6. Antibacterial6. Antibacterial

• GentamycinGentamycin Thrush & Thrush & diarrheadiarrhea

7. Antiasthma7. Antiasthma • AminophyllineAminophylline IrritabilityIrritability

8. Antiangina8. Antiangina • VerapamilVerapamil

Compatible but monitor

Side Effects

9. Antihypertensive • Hydralazine (apresoline)

• Nifedipine

10. Diagnostic Agent

• Propyliodine Hypothyroidism

11. Anticonvulsant • Phenobarbital (luminal)

• MgSO4

• Drowsiness• Poor suckling /

weight gain

12. Analgesic /Anti-

pyretic

• ASA (occasional dose)

Compatible but monitor

RECOMMENDATIONS:RECOMMENDATIONS:

Notify mother….Notify mother….

If + side effects If + side effects stop taking the drugs stop taking the drugs and find alternativeand find alternativeIf mother cannot stop taking the drugs If mother cannot stop taking the drugs

stop stop breastfeeding breastfeeding and feed with and feed with pasteurized milkpasteurized milk

Continue milk expression Continue milk expression

III. Avoid if Possible, monitor for III. Avoid if Possible, monitor for side effectsside effects

(repeated doses (repeated doses serious side effects) serious side effects)

1. Antihistaminic1. Antihistaminic • ChlorphenamineChlorphenamine • DrowsinessDrowsiness• IrritabilityIrritability

2. Hypnosedative2. Hypnosedative • DiazepamDiazepam • DrowsinessDrowsiness

3. Opioid 3. Opioid AnalgesicAnalgesic

• Pethidine Pethidine

• MorphineMorphine

• ApneaApnea• BradycardiaBradycardia

4. Antibiotics4. Antibiotics • TetracyclineTetracycline

• ChlorampenicolChlorampenicol

• Teeth Teeth stainingstaining

• HemolysisHemolysis• JaundiceJaundice

5. Disinfectant5. Disinfectant • Povidone Povidone Iodine Iodine (Topical)(Topical)

• HypothyroidismHypothyroidism

6. Anti-angina6. Anti-angina/ / AntihypertensiveAntihypertensive

• AtenololAtenolol • BradycardiaBradycardia• HypotensionHypotension• CyanosisCyanosis

7. 7. PsychotherapeuticPsychotherapeutic

• ChlorpromazineChlorpromazine

• LithiumLithium

• DrowsinessDrowsiness• Restlessness Restlessness • WeaknessWeakness• Poor muscle Poor muscle

tonetone

8. Antibacterial8. Antibacterial • MetronidazoleMetronidazole

Avoid if possible

9.9. Antitussives Antitussives • Codeine in Codeine in repeated dosesrepeated doses

• ApneaApnea• BradycardiaBradycardia• CyanosisCyanosis

10. Ethanol10. Ethanol

IntakeIntake

• Chronic use of Chronic use of alcohol alcohol

• DrowsinessDrowsiness• Poor growthPoor growth• WeaknessWeakness

11. Caffeine11. Caffeine • Excessive Excessive dosagedosage

• WakefulnessWakefulness• HyperactivityHyperactivity• Poor sleeping Poor sleeping

patternpattern• Irritability Irritability

Avoid if possible

RECOMMENDATIONS:RECOMMENDATIONS:

• Use when essential for mother’s Rx and no safer alternative

• Continue breastfeeding and observe the baby for any changes

• Follow up + side effects stop the drugs

If not possible to stop the drugs stop BF and use pasteurized milk.

• Milk expression

IV. Avoid if Possible (May Inhibit Lactation)

1. Anti-cholinergic1. Anti-cholinergic • AtSO4 (repeated dosesAtSO4 (repeated doses

2. Anti-gout2. Anti-gout • ColchicineColchicine

3. Diuretics3. Diuretics • FurosemideFurosemide• Hydrochlorothia-zideHydrochlorothia-zide

4. Oxytocin4. Oxytocin • Ergometrine Ergometrine (repeated doses)(repeated doses)

• Oxytocin (prolonged use)Oxytocin (prolonged use)

5. Hormonal Con-5. Hormonal Con-traceptivestraceptives

• EthinylestradiolEthinylestradiol• LevonorgestrilLevonorgestril• Ethinyl estradiolEthinyl estradiol

+ Norethisterone+ Norethisterone

6. Anti-parkinsonism6. Anti-parkinsonism • CarbidopaCarbidopa• LevodopaLevodopa

7. Excess Nicotine Intake7. Excess Nicotine Intake • Cigarettes more than Cigarettes more than 20/day20/day

8. Anti-migraine8. Anti-migraine • Ergot alkaloidErgot alkaloid• Ergot ergotamineErgot ergotamine

(May Inhibit Lactation)

RECOMMENDATION:RECOMMENDATION:

Frequent Suckling Frequent Suckling of the Breastof the Breast

V. Avoid V. Avoid (Dangerous Side Effects on (Dangerous Side Effects on the Baby)the Baby)

1. Anti-neoplastic

• Cytotoxic– Cisplatin– Vincristine– Methotrexate

• Immunosuppresive– Ciclosporin– Azathioprine

2. Radiopharmaceutical Anti-2. Radiopharmaceutical Anti-thyroidthyroid

- iodine 131 or Na iodide - iodine 131 or Na iodide

(Na 131)(Na 131)

Elimination of Radio-iodine from Elimination of Radio-iodine from the milkthe milk

Na 131 - 14 daysNa 131 - 14 days

Iodine 123 - 36 hoursIodine 123 - 36 hours

125 - 12 days125 - 12 days

Cause Cause damage to damage to nursing infant nursing infant thyroidthyroid

Increase risk Increase risk of thyroid CAof thyroid CA

AVOID

3. Hallucinogenic

• Marijuana• LSD• PCP (Phen-

cyclidine)

• Irritability• Poor feeding

4. Anorexant / Appetite, suppresant

• Phentermine• Amphetamine

• CNS stimulation

may occur in nursing infant

5. Anti-lipemic • Simvastatin• Fluvastatin

AVOID

RECOMMENDATION:RECOMMENDATION:

Stop breastfeeding untilStop breastfeeding until

treatment is completedtreatment is completed

Is there a drug that is Is there a drug that is absolutely safe?absolutely safe?

EFFECTS OF DRUGS TO THE MOTHEREFFECTS OF DRUGS TO THE MOTHER

1. Estrogen /Thiazide1. Estrogen /Thiazide • Suppress lactationSuppress lactation

2. Rifampicin (Orange)2. Rifampicin (Orange) • Colors breastmilkColors breastmilk

3. Metronidazole 3. Metronidazole

IothalamateIothalamate

Flavors breast milkFlavors breast milk• (Bitter taste) Onion, (Bitter taste) Onion,

GarlicGarlic• (Radiographic Contrast (Radiographic Contrast

Media) metalic tasteMedia) metalic taste

4. Metoclopramide4. Metoclopramide • Increase lactationIncrease lactation

5. Nicotine5. Nicotine • Decrease milk productionDecrease milk production

1. Diazepam

/ Phenobarbital

• Lethargy• Drowsiness• Sedation

2. Chlorphenamine

/ Theophylline

• Irritability

3. Indomethacin • Convulsion

4. Phenobarbital

/ Carbamazepine

• Poor suckling• Poor weight gain

EFFECTS OF DRUGS TO THE BABYEFFECTS OF DRUGS TO THE BABY

5. Clindamycin5. Clindamycin • Bloody Bloody DiarrheaDiarrhea

6. Gentamycin

/ Streptomycin

• Diarrhea Diarrhea /Thrush/Thrush

7. AtSO4 • FeverFever• Drying of Drying of

secretionsecretion

8. Penicillin • RashesRashes

9. Anti-TB

/Ascorbic Acid (large doses)

/ Chloramphenicol

• JaundiceJaundice

EFFECTS OF DRUGS TO THE BABYEFFECTS OF DRUGS TO THE BABY

10. Lithium10. Lithium • Restlessness• Weakness• Poor muscle tone

11. Propranolol • Hypoglycemia• Cyanosis

12. Nicotine

(chewing gum)

• Vomiting• Tachycardia• Restlessness

13. ASA • Hemolysis• Prolonged bleeding time

EFFECTS OF DRUGS TO THE BABYEFFECTS OF DRUGS TO THE BABY

14. K Iodide14. K Iodide

/ Povidone / Povidone IodineIodine

• HypothyroidismHypothyroidism

15. Caffeine15. Caffeine • HyperactivityHyperactivity• WakefulnessWakefulness• Slow excretionSlow excretion• Poor sleeping patternPoor sleeping pattern

16. Tetracycline16. Tetracycline • Staining teethStaining teeth

17. Morphine17. Morphine

/ Pethidine/ Pethidine

• ApneaApnea• BradycardiaBradycardia

18. Morphine18. Morphine • Urinary RetentionUrinary Retention

EFFECTS OF DRUGS TO THE BABYEFFECTS OF DRUGS TO THE BABY

MEASURES TO MINIMIZE EFFECT OF MEASURES TO MINIMIZE EFFECT OF MATERNAL MEDICATIONMATERNAL MEDICATION

• Avoid long acting forms of drug.Avoid long acting forms of drug.

• Schedule the doseSchedule the dose

• Choose the safest drugChoose the safest drug

• Watch out for signs and Watch out for signs and symptoms symptoms

• If a drug may present a risk to the If a drug may present a risk to the infant measure blood infant measure blood

concentrations.concentrations.

Medicines in LactationMedicines in Lactation

judgementjudgement1. Requirement1. Requirement

careful careful assessment assessment of Risk of Risk of not givingof not giving

vs. Harmvs. Harm

indicationindication2. Usage

proven benefitsproven benefits

Salamat Po !Salamat Po !