Medications and Lactation: Principles for Safe Practice for the Clinician

Evelyn Fulmore, Pharm.D.

McLeod Regional Medical Center

Florence, SC

Disclosures

No financial relationships or duality of interest to disclose

I will be discussing use of agents to improve milk supply (galactagogues)

Learning Objectives

Basic physiology of lactation and mechanisms of medication entry into mother’s breast milk

Factors to consider when selecting medications during lactation

Role of galactagogues in lactation induction Tips in utilizing and interpreting available

lactation drug information resources

Physiology of LactationPhysiology of Lactation

Suckling stimulates Suckling stimulates nipple nipple →→ pituitary gland pituitary gland secretes oxytocin secretes oxytocin →→ let let down reflex results in down reflex results in milk ejecting cells milk ejecting cells contract forcing milk contract forcing milk from milk cells into milk from milk cells into milk ducts.ducts.

Physiology of LactationPhysiology of Lactation

Milk pools in laciferous Milk pools in laciferous sinuses under the sinuses under the areola. Suckling areola. Suckling stimulates milk to come stimulates milk to come from the nipple.from the nipple.

Composition of BreastmilkComposition of Breastmilk

ColostrumColostrum (Days #3-5) (Days #3-5)

high protein, immunoglobulins, minerals, low in high protein, immunoglobulins, minerals, low in lactose and fatlactose and fat

Transitional milkTransitional milk (Days #6-10) (Days #6-10)

high in fat, lactose; lower in protein and mineralshigh in fat, lactose; lower in protein and minerals Mature milkMature milk (Day #14) (Day #14)

60-80% whey protein, 50% fat, 40% lactose, growth 60-80% whey protein, 50% fat, 40% lactose, growth factor, low in Vitamin D factor, low in Vitamin D

Factors Affecting Amount of Drug Received by the Infant

Milk yield Colostrum versus Mature milk Concentration of drug in the milk How well the breast was emptied during the

previous feeding Infants ability to absorb, detoxify, and excrete

the drug

Transfer of Medications into Transfer of Medications into Breast MilkBreast Milk

Concentration gradientConcentration gradient– Passive diffusion of non-ionized and free (non-Passive diffusion of non-ionized and free (non-

protein bound) medsprotein bound) meds– Maternal serum drug concentrationMaternal serum drug concentration

volume of distribution (Vd) and half-life volume of distribution (Vd) and half-life - Retrograde diffusion of drug from breast milk to Retrograde diffusion of drug from breast milk to

plasmaplasma

Spencer JP et.al. Medications in the Breast-Feeding Mother. AFP 2001; Spencer JP et.al. Medications in the Breast-Feeding Mother. AFP 2001; 64:11964:119

Transfer of Medications into Transfer of Medications into Breast MilkBreast Milk

1.1. Lipid solubilityLipid solubility

2.2. Molecular weightMolecular weight

3.3. Maternal plasma levelsMaternal plasma levels

4.4. Maternal protein bindingMaternal protein binding

5.5. Oral bioavailability, half lifeOral bioavailability, half life

6.6. Ion trapping (pKa)Ion trapping (pKa)

Lipid SolubilityLipid Solubility

Drugs that are highly lipid soluble penetrate Drugs that are highly lipid soluble penetrate milk in higher concentrationsmilk in higher concentrations

Avoid extremely lipid soluble drugs.Avoid extremely lipid soluble drugs. Examples: Diazepam, phenobarbitalExamples: Diazepam, phenobarbital

Molecular WeightMolecular Weight

The lower the molecular weight (<200 D), the The lower the molecular weight (<200 D), the greater penetration into milkgreater penetration into milk

Molecular weights <300 D : (eg. Alcohol, Molecular weights <300 D : (eg. Alcohol, amphetamines, diet pills)amphetamines, diet pills)

Molecular weights Molecular weights ≥ 600 D : (eg. Heparin, ≥ 600 D : (eg. Heparin, Enoxaparin, Insulin, Remicade)Enoxaparin, Insulin, Remicade)

Larger the molecular weight/size (preferred)Larger the molecular weight/size (preferred)

Maternal Plasma levelMaternal Plasma level

The most important determinant of drug The most important determinant of drug penetration into milkpenetration into milk

As maternal plasma levels rise, the As maternal plasma levels rise, the concentration in milk risesconcentration in milk rises

Drug delivery systems that result in low Drug delivery systems that result in low maternal plasma levels are preferred in maternal plasma levels are preferred in breast feeding mother (eg. Inhaler med, breast feeding mother (eg. Inhaler med, topicals) topicals)

Maternal Protein BindingMaternal Protein Binding

Most important parameter in choosing a Most important parameter in choosing a safe drug for a nursing mother safe drug for a nursing mother

Most drugs circulate in the maternal Most drugs circulate in the maternal plasma bound to albuminplasma bound to albumin

““Free” or “Unbound” drug transfers into Free” or “Unbound” drug transfers into milkmilk

Drugs that are highly protein bound Drugs that are highly protein bound remain in the maternal plasma and don’t remain in the maternal plasma and don’t penetrate tissues or breast milkpenetrate tissues or breast milk

Oral BioavailabilityOral Bioavailability

The amount of drug that is absorbed by the The amount of drug that is absorbed by the infant’s GI tract and reaches the circulationinfant’s GI tract and reaches the circulation

Low oral bioavailability: aminoglycosides, Low oral bioavailability: aminoglycosides, heparin, insulin, omeprazoleheparin, insulin, omeprazole

Action of a drug in the GI tract may produce Action of a drug in the GI tract may produce SE: diarrhea, constipation, PMCSE: diarrhea, constipation, PMC

Ion Trapping (pKa)Ion Trapping (pKa)

Ion trapping – drug becomes trapped in milk Ion trapping – drug becomes trapped in milk compartment (due to low pH milk)compartment (due to low pH milk)

pKa is the pH where a drug is equally ionic or pKa is the pH where a drug is equally ionic or nonionic (the more ionic, less transfer from nonionic (the more ionic, less transfer from milk to plasma)milk to plasma)

Drugs with high pKa (>7.2), have higher Drugs with high pKa (>7.2), have higher Milk/Plasma ratio (eg.Phenobarbital, Milk/Plasma ratio (eg.Phenobarbital, iodinated drugs)iodinated drugs)

Choose drugs with a low pKaChoose drugs with a low pKa

Drugs That Decrease Milk SupplyDrugs That Decrease Milk Supply

NicotineNicotine Alcohol Alcohol Sedating Antihistamines (eg. Diphenhydramine)Sedating Antihistamines (eg. Diphenhydramine) Estrogen containing oral contraceptivesEstrogen containing oral contraceptives Progesterone contraceptives (if started early Progesterone contraceptives (if started early

postpartum before milk supply established)postpartum before milk supply established) Bromocriptine (Parlodel)Bromocriptine (Parlodel)

Drugs That Aid in Milk Production:Galactagogues

Herbals: Fenugreek Metoclopramide (Reglan) Domperidone (Motillium) Synthetic Oxytocin nasal spray

Galactagogues

Used to increase breast milk supply Need to determine the etiology of low milk

supply Ensure proper breastfeeding technique Only use with adequate milk removal Must evaluate for medical co-morbidities

(e.g. hypothyroidism, retained placenta)

Herbal: Fenugreek

Trigonella foenum graecum MOA: stimulate sweat production;

Phytoestrogen and Diosgenin - increase milk flow

Tea (bitter taste), capsule or tablet Sweat and urine (maple syrup smell) Caution use in Asthma or diabetes Contains coumarin (interact with

NSAIDS) No scientific data

Domperidone (Motillium)

Not approved for use in the US MOA: increase prolactin → milk production Maternal safety has not been established FDA warning concerning reports of QT

interval prolongation, cardiac arrest, sudden death (IV formulation)

Clinical trial showed increase breastmilk volume without affecting nutrient composition

Campbell-Yeo M. Effect of Domperidone on Compositiono of Preterm Human Breast Milk. Pediatrics 2010; 125 (1):e107-e114

Metoclopramide (Reglan)

Most commonly used MOA: increase prolactin Caution: clearance of metoclopramide in the

neonate is prolonged can result in side effects (methemoglobinemia)

Short term use recommended (1-3 weeks) Common dosing: 1st day – 10 mg, 2nd day – 10

mg bid, thereafter 10 mg tid

Synthetic Oxytocin Nasal Spray

Hormone (synthetically derived) MOA: causes release of milk from milk

glands to the ducts (helps empty the breast) Prepared by compounding Rx (10 unit/ml) Dose: 1-2 sprays each nostril before breast

feeding or pumping

Synthetic Oxytocin Nasal Spray:Mean Daily Milk Production

Fewtrell MS. Arch Dis Child Fetal Neonatal Ed. 2006 May; 91(3): F169–F174.

Safety Data and Breast FeedingSafety Data and Breast Feeding

Breast feeding lacks standardized risk Breast feeding lacks standardized risk categoriescategories

Most of the data on meds and breast feeding Most of the data on meds and breast feeding are from scientific literatureare from scientific literature

Given the lack of standardization, other Given the lack of standardization, other recommendations for using meds while recommendations for using meds while breast feeding have been used by health breast feeding have been used by health care providerscare providers

Master KP et.al . Breast Feeding and OTC medications. US Pharm 2007; 32 (7): 8-12Master KP et.al . Breast Feeding and OTC medications. US Pharm 2007; 32 (7): 8-12

Lactation ResourcesLactation Resources

BooksBooks– Gerald G. Briggs. “Gerald G. Briggs. “Drugs Drugs

in Pregnancy and in Pregnancy and Lactation: A reference Lactation: A reference Guide to Fetal and Guide to Fetal and Neonatal Risk”, 9Neonatal Risk”, 9 thth edition; 2012edition; 2012

Briggs GG et. al. Drugs in Pregnancy and Briggs GG et. al. Drugs in Pregnancy and Lactation, 2008; 8th editionLactation, 2008; 8th edition

Definitions of Breast Feeding Recommendations

Compatible Hold Breast Feeding No (limited) Human Data – Probably Compatible No (limited) Human Data – Potential Toxicity No (limited) Human Data – Potential Toxicity

(Mother) Contraindicated

Lactation ResourcesLactation Resources

BooksBooks– Thomas W. Hale. Thomas W. Hale.

““Medications and Medications and Mothers’ Milk” 2012, 15Mothers’ Milk” 2012, 15 thth editionedition

Hale TW. Medications and Mothers' Milk, 2010; Hale TW. Medications and Mothers' Milk, 2010; 14th edition.14th edition.

Dr. Hale’s Lactation Risk Category

L1 Safest L2 Safer L3 Moderately Safe L4 Potentially Hazardous L5 Contraindicated

Dr. Hale’s Lactation Risk CategoryDr. Hale’s Lactation Risk Category

L1 L1 SafestSafest: Drug taken by larger # of breast : Drug taken by larger # of breast feeding women without any observed feeding women without any observed adverse effects in infantadverse effects in infant

L2 L2 SaferSafer: Drug studied in a limited # of : Drug studied in a limited # of breast feeding women without any observed breast feeding women without any observed adverse events in infantsadverse events in infants

L3 L3 Moderately SafeModerately Safe: No controlled trials in : No controlled trials in breast feeding women, but risk of untoward breast feeding women, but risk of untoward effects is possibleeffects is possible

Dr. Hale’s Lactation Risk Category Dr. Hale’s Lactation Risk Category

L3 L3 Moderately SafeModerately Safe: No controlled trials in : No controlled trials in breast feeding women, but risk of untoward breast feeding women, but risk of untoward effects is possible effects is possible OR OR controlled studies controlled studies show only minimal non-threatening adverse show only minimal non-threatening adverse effectseffects

L4 L4 Potentially HazardousPotentially Hazardous: Positive : Positive evidence of risk to the breastfed infant evidence of risk to the breastfed infant OROR to to the breast milk production but benefit the breast milk production but benefit outweighs the riskoutweighs the risk

Dr. Hale’s Lactation Risk Category Dr. Hale’s Lactation Risk Category

L5 L5 ContraindicatedContraindicated: Studies in : Studies in breastfeeding women have demonstrated breastfeeding women have demonstrated significant and documented risk to the infant. significant and documented risk to the infant. Risk clearly outweighs benefits of breast Risk clearly outweighs benefits of breast feeding.feeding.

Values Used to Estimate Infant Drug Exposure

Milk to Plasma Ratio (M/P) – Ratio of the concentration of drug in mother’s milk divided by the

concentration in the mother’s plasma– M/P <1 is preferred

Theoretical Infant Dose (TID)– Multiply the milk concentration x daily milk intake of the infant– Compared to the usual maintenance pediatric dose

Relative Infant Dose (RID) – Divide the infant’s dose via milk (mg/kg/day) by the mother’s dose

(mg/kg/day) – Assumes daily milk intake of 150 ml/kg/day– RID<10% is considered safe– Exception: fluconazole, metronidazole (have a high RID but are

non toxic)

Lactation ResourcesLactation Resources

Internet Internet – Dr. Hale’s Breastfeeding Dr. Hale’s Breastfeeding

Pharmacology page Pharmacology page ((

http://www.neonatal.ttuhsc.edu/facthttp://www.neonatal.ttuhsc.edu/fact))

Lactation ResourcesLactation Resources

InternetInternet– U.S. National Library of U.S. National Library of

Medicine. Medicine. LactMed LactMed

(http://toxnet.nlm.nih.gov/cgi-(http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?)/LACT)bin/sis/htmlgen?)/LACT)

LactMed

LactMed

Linezolid (Zyvox)

The Transfer of Drugs and Other Chemicals Into Human MilkCommittee on DrugsPediatrics 2001;108;776

CLINICAL REPORTThe Transfer of Drugs and Therapeutics Into HumanBreast Milk: An Update on Selected TopicsHari Cheryl Sachs, MD, FAAP* and COMMITTEE ON DRUGSPediatrics; originally published online August 26, 2013; DOI: 10.1542/peds.2013-1985

BeforeBefore Prescribing Drug Therapy in the Prescribing Drug Therapy in the Lactating WomanLactating Woman

1.1. Is drug therapy really necessary?Is drug therapy really necessary?

2.2. The safest drug should be chosen.The safest drug should be chosen.

3.3. If there is a possibility that a drug may If there is a possibility that a drug may present a risk to the infant, then consider present a risk to the infant, then consider measuring blood levels measuring blood levels

4.4. Drug exposure in the infant may be limited Drug exposure in the infant may be limited by timing of med and breastfeeding by timing of med and breastfeeding

AAP Committee on Drugs. The transfer of drugs and other chemicals AAP Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics 2001;108 (3):777into human milk. Pediatrics 2001;108 (3):777

AnalgesicsAnalgesics

Acetaminophen (Tylenol) is compatible with breast Acetaminophen (Tylenol) is compatible with breast feedingfeeding

Nonsteroidal antiinflammatory drugs (NSAIDS) – Nonsteroidal antiinflammatory drugs (NSAIDS) – ibuprofen is preferredibuprofen is preferred– Naprosyn, sulindac, piroxicam should be avoidedNaprosyn, sulindac, piroxicam should be avoided

Narcotic/Opiates – morphine, codeine, oxycodone, Narcotic/Opiates – morphine, codeine, oxycodone, and hydrocodone are compatible with breast feedingand hydrocodone are compatible with breast feeding– Meperidine (Demerol) should be avoidedMeperidine (Demerol) should be avoided

Narcotics/Opiates

Case controlled studies evaluating long term developmental outcomes are needed

Breastfeeding should be supported if:– “stable” and compliant with methadone or

buprenorphine +/- naloxone (Subutex®, Suboxone®)– negative maternal urine toxicology test at delivery

except for prescribed medications– plan to continue substance abuse treatment in the

postpartum period– do not have medical contraindication to breastfeeding

Breastfeeding Medicine 2009; 4(4):225-228

AntibioticsAntibiotics

Penicillins and cephalosporins are compatible with breast Penicillins and cephalosporins are compatible with breast feedingfeeding

– Monitor infant for diarrhea (change in gut flora)Monitor infant for diarrhea (change in gut flora) Tetracycline is compatible with breast feedingTetracycline is compatible with breast feeding

– Calcium in breast milk limits absorption ; avoid doxycyline and Calcium in breast milk limits absorption ; avoid doxycyline and minocyclineminocycline

Quinolones have not been rated by AAPQuinolones have not been rated by AAP– Levaquin is compatible with breast feedingLevaquin is compatible with breast feeding

Trimethoprim-sulfamethoxazole (Bactrim) is compatible with Trimethoprim-sulfamethoxazole (Bactrim) is compatible with breast feedingbreast feeding

– Not recommended in infants < 2 month (deplacement of bilirubin)Not recommended in infants < 2 month (deplacement of bilirubin)

AntidepressantsAntidepressants

Tricyclic antidepressants – little or no effect on breast feeding Tricyclic antidepressants – little or no effect on breast feeding infantinfant

– AAP lists as possible concern with exposure long-term AAP lists as possible concern with exposure long-term Selective serotonin reuptake inhibitors (SSRIs) – generally 1Selective serotonin reuptake inhibitors (SSRIs) – generally 1 stst

choicechoice– Paroxetine (Paxil) or Sertraline (Zoloft) preferred to Paroxetine (Paxil) or Sertraline (Zoloft) preferred to

Fluoxetine (Prozac)Fluoxetine (Prozac) Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

– Venlafaxine (Effexor) Venlafaxine (Effexor) Take dose at bedtime to limit exposure to infantTake dose at bedtime to limit exposure to infant

Antidepressants: SSRIs and SNRIs

Limited to small case studies Paroxetine and sertraline produced low RID 0.5-3% Fluoxetine, citalopram, venlafaxine have variable

RID near to equal 10% Preference hierarchy: sertraline, paroxetine,

citalopram, venlafaxine, fluoxetine Watch for uneasy sleep, colic, irritability, poor

feeding, drowsiness

Breastfeeding Medicine 2008; 3 (1): 44-52

Relative Infant Dose (RID) of Commonly Prescribed Antidepressants

Antidepressant Relative Infant Dose (%)

Buproprion (Wellbutrin) 2

Citalopram (Celexa) 3-10

Desvenlafaxine (Khedezla) 5.5-8.1

Duloxetine (Cymbalta) <1

Escitalopram (Lexapro) 3-6

Fluoxetine (Prozac) <12

Fluvoxamine (Luvox) <2

Mirtazapine (Remeron) 0.5-3

Paroxetine (Paxil) 0.5-3

Sertraline (Zoloft) 0.5-3

Venlafaxine (Effexor) 6-9

Chad L et.al. Update on antidepressant use during breastfeeding. Canadian Fam Physician 2013; 59: 633-634.

Antiepileptic MedsAntiepileptic Meds

Phenytoin, Carbamazepine, and Valproic acid are Phenytoin, Carbamazepine, and Valproic acid are compatible with breast feedingcompatible with breast feeding– Caution in use due to risk for hepatotoxicity Caution in use due to risk for hepatotoxicity

(Valproate)(Valproate) Lamotrigine (Lamictal), Primadone (Mysoline), Lamotrigine (Lamictal), Primadone (Mysoline),

Phenobarbital are compatible with breast feedingPhenobarbital are compatible with breast feeding– not preferred due to slow metabolism in the infant not preferred due to slow metabolism in the infant

resulting in sedationresulting in sedation Levetiracetam (Keppra) and Topiramate (Topamax) Levetiracetam (Keppra) and Topiramate (Topamax)

appear compatible with breastfeedingappear compatible with breastfeeding

Antiepileptic meds:Topiramate and Levetiracetam

5 mother child pairs on Topiramate – mean milk:plasma ratio 0.86 – Topiramate concentrations in infant were low– 4 of 5 mothers also taking carbamazepine (inducer)

8 women on Levetiracetam– Milk and plasma concentration equal– Levetiracetam concentrations in infants were low

Ohman I et.al. Topiramate kinetics during delivery and lactation. Epilepsia 2002; 43: 1157-1160Johannasen SI et.al. Levetiracetam concentrations in serum and breast milk at birth and during lactaction. Epilepsia 2005; 46: 775-777

AntihistaminesAntihistamines

All sedating antihistamines have the All sedating antihistamines have the possibility of causing sedation in the infantpossibility of causing sedation in the infant

Sedating antihistamines (esp. with Sedating antihistamines (esp. with decongestant) can decrease milk supplydecongestant) can decrease milk supply

Nonsedating antihistamines are compatible Nonsedating antihistamines are compatible with breast feedingwith breast feeding– Loratadine (Claritin) preferredLoratadine (Claritin) preferred

Blood Pressure MedsBlood Pressure Meds

Diuretics are compatible with breast feedingDiuretics are compatible with breast feeding– Avoid high dosesAvoid high doses

Beta blockers are compatible with breast feedingBeta blockers are compatible with breast feeding– Propranolol, metoprolol, and labetalol preferredPropranolol, metoprolol, and labetalol preferred– Atenolol, nadolol, and sotalol can lead to SE (hypotension, Atenolol, nadolol, and sotalol can lead to SE (hypotension,

bradycardia, tachypnea)bradycardia, tachypnea)

Calcium channel blockers (CCBs) are compatible Calcium channel blockers (CCBs) are compatible with breast feedingwith breast feeding– Nifedipine (Procardia) is preferredNifedipine (Procardia) is preferred

ACE inhibitors and ARBs must use with cautionACE inhibitors and ARBs must use with caution

Diabetes MedsDiabetes Meds

Insulin is compatible with breast feedingInsulin is compatible with breast feeding 22ndnd Generation sulfonylureas (eg. glyburide, Generation sulfonylureas (eg. glyburide,

glipizide, glimeperide) are compatible with breast glipizide, glimeperide) are compatible with breast feedingfeeding

Metformin is compatible with breast feedingMetformin is compatible with breast feeding Limited data with use of thioglitazones (eg. Limited data with use of thioglitazones (eg.

AvandiaAvandia®®, Actos, Actos®®) ) Monitor infants for symptoms of hypoglycemiaMonitor infants for symptoms of hypoglycemia

Diabetes Meds: Glyburide and Glipizide

Nonrandomized controlled study Single dose of glyburide (5 or 10 mg, n=8) Daily dose of glyburide or glipizide (5 mg; n=5) No glyburide was found in milk Mean infant exposure < 1.5% Blood glucose levels were normal Glyburide and glipizide compatible with

breastfeeding

Feig DS et.al. Transfer of glyburide and glipizide into breast milk. Diabetes Care 2005; 28:1851-5

Diabetes Meds: MetforminDiabetes Meds: Metformin

Prospective studyProspective study 61 breast fed, 50 formula fed infants 61 breast fed, 50 formula fed infants Evaluate growth, motor-social development or Evaluate growth, motor-social development or

illnessillness Median metformin dose 2.55 grams per dayMedian metformin dose 2.55 grams per day 6 months of life - no difference in weight, ht, motor-6 months of life - no difference in weight, ht, motor-

social development, illness (p social development, illness (p ≥ 0.06)≥ 0.06) Mean infant exposure 0.28-1.08%Mean infant exposure 0.28-1.08% Metformin safe in 1Metformin safe in 1stst 6 months of life 6 months of life

Glueck CJ et.al. J Pediatrics 2006; 148 (5): 628-632

Medications Contraindicated in Medications Contraindicated in Breast FeedingBreast Feeding

AntineoplasticsAntineoplastics Immune suppressantsImmune suppressants Ergot alkaloidsErgot alkaloids GoldGold Iodine/Radiocontrast mediaIodine/Radiocontrast media Lithium carbonateLithium carbonate Certain antibioticsCertain antibiotics Social drugs and drugs of abuseSocial drugs and drugs of abuse

Minimizing Potential Risk to Nursing Minimizing Potential Risk to Nursing Infants from Maternal MedicationsInfants from Maternal Medications

General ConsiderationsGeneral Considerations– Avoid drug therapy when possibleAvoid drug therapy when possible– Use topical therapy when possibleUse topical therapy when possible– Meds that are safe for use in the infant ARE generally safe Meds that are safe for use in the infant ARE generally safe

for the breast-fed motherfor the breast-fed mother– Meds that are safe in pregnancy are NOT always safe in Meds that are safe in pregnancy are NOT always safe in

breast-feedingbreast-feeding– Use reliable references for obtaining info on meds in breast Use reliable references for obtaining info on meds in breast

milkmilk

Spencer JP et. al. Medications in the Breast-Feeding Mother. AFP Spencer JP et. al. Medications in the Breast-Feeding Mother. AFP 2001,64:1202001,64:120

Minimizing Potential Risk to Nursing Minimizing Potential Risk to Nursing Infants from Maternal MedicationsInfants from Maternal Medications

Medication dosingMedication dosing– Administer single daily dose meds just Administer single daily dose meds just beforebefore the the

longest sleep interval for the infant, usually after longest sleep interval for the infant, usually after the bedtime feedingthe bedtime feeding

– Breastfeed infant immediately Breastfeed infant immediately beforebefore med dose med dose when multiple daily doses are neededwhen multiple daily doses are needed

Spencer JP. Medications in the Breast-Feeding Mother.AFP, 2001: Spencer JP. Medications in the Breast-Feeding Mother.AFP, 2001: 64:12064:120

ConclusionConclusion

Healthcare providers should encourage Healthcare providers should encourage mothers to breast feed mothers to breast feed

Evidence supports most commonly Evidence supports most commonly prescribed meds in breast feeding mothers prescribed meds in breast feeding mothers can be taken safely can be taken safely

Utilize available lactation references Utilize available lactation references Further help can be provided by your Further help can be provided by your

lactation consultant and clinical pharmacistlactation consultant and clinical pharmacist

References

1. Buck, ML. Drugs in Pregnancy and Lactation: Literature an Resource Update. Pediatric Pharm., 2010;16 (1): 1-5.

2. Burkey BW. Evaluating Medication Use in Pregnancy and Lactation: What Every Pharmacist Should Know. J Pediatric Pharmacol Ther 2013; 18(3):247-258.

3. Chad L et.al. Update on Antidepressant Use During Breastfeeding. Canadian Family Physician, 2013; 59: 633-634.

4. Feig DS et. al. Oral Antidiabetic Agents in Pregnancy and Lactation: A Paradigm Shift? The Annals of Pharmacotherapy, 2007:41(7): 1174-1180.

5. Glatstein MM et. al. Use of Hypoglycemic Drugs During Lactation. Canadian Family Physician, 2009; 55: 371-373.

6. Glueck CJ et.al. Growth, Motor, and Social Development in Breast and Formula-fed Infants of Metformin-treated Women with Polycystic Ovarian Syndrome. J Pediatrics, 2006; 148(5):628-32.

7. Sachs et.al. AAP Committee on Drugs: The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics. Pediatrics, 2013; 132 (3): e796-e809.

8. Mathhew JL. Effect of Maternal Antibiotics on Breast feeding Infants. Postgrad Med Journal, 2004; 80:196-200.

References

9. Mortel M and Mehta SD. Systematic Review of the Efficacy of Herbal Galactogogues. Journal of Human Lactation,2013;29(2):154-162.

10. Pack AM. Therapy Insight: Clinical Management of Pregnant Women with Epilepsy. Nat Clin Pract Neurol, 2006; 2(4):190-200.

11. Wagner CL. Human Milk and Lactation. Medscape, 2012.

12. The Academy of Breastfeeding Medicine (ABM) Protocol Committee. ABM Clinical Protocol #18: Use of Antidepressants in Nursing Mothers. Breast Feeding Medicine, 2008;3(1):44-52.

13. The Academy of Breastfeeding Medicine (ABM) Protocol Committee. ABM Clinical Protocol #21: Guidelines for Breastfeeding and the Drug-Dependent Woman. Breast Feeding Medicine, 2009;4(4):225-228.

14. The Academy of Breastfeeding Medicine (ABM) Protocol Committee. ABM Clinical Protocol #9. Use of Galactogogues in Initiating or Augmenting the Rate of Maternal Milk Secretion. Breast Feeding Medicine, 2011;6(1):41-49.

Thank you!