Medications and Breastfeeding

MEDICATIONS AND MEDICATIONS AND BREASTFEEDING:BREASTFEEDING:BREASTFEEDING: BREASTFEEDING:

What Dispensing Pharmacists What Dispensing Pharmacists Need To KnowNeed To Know

Frank J. Nice, RPh, DPA, CPHPFrank J. Nice, RPh, DPA, CPHPDerwood, MD 20855Derwood, MD [email protected]@hotmail.com

www.nicebreastfeeding.comwww.nicebreastfeeding.comgg301301--840840--0270 (H)0270 (H)240240--506506--2568 (C)2568 (C)

OBJECTIVESOBJECTIVESOBJECTIVESOBJECTIVESBe able to identify the benefits and risks of Be able to identify the benefits and risks of yymedication use during breastfeedingmedication use during breastfeedingBe able to identify available resources for Be able to identify available resources for

di ti d i b tf didi ti d i b tf dimedication use during breastfeedingmedication use during breastfeedingBe able to utilize tools and techniques for Be able to utilize tools and techniques for evaluating medication use during breastfeedingevaluating medication use during breastfeedingevaluating medication use during breastfeedingevaluating medication use during breastfeedingBe 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 tidi timedicationsmedicationsBe able to counsel mothers who are Be able to counsel mothers who are breastfeeding and taking or will take medicationsbreastfeeding and taking or will take medications

22

breastfeeding and taking or will take medicationsbreastfeeding and taking or will take medications

Photo Courtesy of NIHPhoto Courtesy of NIH 33

BenefitBenefit--Risk AnalysisRisk AnalysisBenefitBenefit Risk AnalysisRisk 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)

VersusVersusRisks 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 INFORMATIONSOURCES OF INFORMATIONSOURCES OF INFORMATIONSOURCES OF INFORMATION

Journal ArticlesJournal ArticlesNice ReferencesNice ReferencesNice ReferencesNice ReferencesAAP Committee on DrugsAAP Committee on Drugs (See Website List)(See Website List)MICROMEDEX (See Website List)MICROMEDEX (See Website List)

BooksBooksBooksBooksNNonprescription Drugs for the Breastfeeding Mother, 2onprescription Drugs for the Breastfeeding Mother, 2ndnd EditionEdition

Nice (See Slide)Nice (See Slide)Medications and Mothers’ Milk 15Medications and Mothers’ Milk 15thth EditionEditionMedications and Mothers Milk, 15Medications and Mothers Milk, 15 EditionEdition

Hale Hale (See Slide)(See Slide)Drugs in Pregnancy and Lactation, 9Drugs in Pregnancy and Lactation, 9thth Edition Edition

Briggs, Freeman, and Yaffe (See Slide)Briggs, Freeman, and Yaffe (See Slide)Drugs and Human Lactation, 2Drugs and Human Lactation, 2ndnd EditionEdition

Bennett (WHO)Bennett (WHO)

55

SOURCES OF INFORMATIONSOURCES OF INFORMATIONSOURCES OF INFORMATIONSOURCES OF INFORMATION

Pharmaceutical CompaniesPharmaceutical CompaniesPharmaceutical CompaniesPharmaceutical CompaniesWebsites Websites (See Next Slide)(See Next Slide)Lactation Study CenterLactation Study CenterLactation Study CenterLactation Study Center

Ruth Lawrence, MDRuth Lawrence, MD

University of RochesterUniversity of RochesterUniversity of RochesterUniversity of Rochester601 Elmwood Avenue, Rochester, NY 14642601 Elmwood Avenue, Rochester, NY 14642(585) 275(585) 275--0088; Mon0088; Mon--Fri 8AMFri 8AM--5PM5PM(585) 275(585) 275 0088; Mon0088; Mon Fri, 8AMFri, 8AM 5PM5PM

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BREASTFEEDING WEBSITESBREASTFEEDING WEBSITESBREASTFEEDING WEBSITESBREASTFEEDING WEBSITES

Nice BreastfeedingNice Breastfeedingwww.nicebreastfeeding.comwww.nicebreastfeeding.com

LactMed / TOXNET / NLM / NIHLactMed / TOXNET / NLM / NIHLactMed / TOXNET / NLM / NIHLactMed / TOXNET / NLM / NIHhttp://toxnet.nlm.nih.gov/cgihttp://toxnet.nlm.nih.gov/cgi--bi / i /ht l ?LACTbi / i /ht l ?LACTbin/sis/htmlgen?LACTbin/sis/htmlgen?LACT

Thomas Hale InfantRisk CenterThomas Hale InfantRisk Centerhttp://www.infantrisk.com/category/http://www.infantrisk.com/category/breastfeedingbreastfeeding

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breastfeedingbreastfeeding

BREASTFEEDING WEBSITESBREASTFEEDING WEBSITESBREASTFEEDING WEBSITESBREASTFEEDING WEBSITES

Breastfeeding OnlineBreastfeeding Onlinehttp://breastfeedingonline.comhttp://breastfeedingonline.com

KellyMomKellyMomyyhttp://www.KellyMom.comhttp://www.KellyMom.com

American Academy of Pediatrics Policy Statement: The Transfer ofAmerican Academy of Pediatrics Policy Statement: The Transfer ofAmerican Academy of Pediatrics Policy Statement: The Transfer of American Academy of Pediatrics Policy Statement: The Transfer of Drugs and Other Chemicals Into Human MilkDrugs and Other Chemicals Into Human Milk

http://aappolicy.aappublications.org/cgi/http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b108/3/776content/full/pediatrics%3b108/3/776pp

MICROMEDEX Healthcare SeriesMICROMEDEX Healthcare Series(Subscription Required)(Subscription Required)

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(Subscription Required)(Subscription Required)http://www.micromedex.com/products/hcs/http://www.micromedex.com/products/hcs/

DRUG FACTORSDRUG FACTORS--IIG l G id liG l G id liGeneral GuidelinesGeneral Guidelines

1.1. Most drugs appear in breast milk to some degreeMost drugs appear in breast milk to some degree

22 Levels of most drugs in breast milk do not usuallyLevels of most drugs in breast milk do not usually2.2. 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 dosageexceed 1% to 2% of ingested maternal dosage

33 If the milk/plasma ratio of drug and activeIf the milk/plasma ratio of drug and active3.3. 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 usuallyusually safe to safe to breastfeedbreastfeed

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

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DRUG FACTORSDRUG FACTORS--IIIIPharmacokineticsPharmacokinetics

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 ProteinProtein--Bound Drugs (85%)Bound Drugs (85%)4.4. ProteinProtein--Bound Drugs (85%)Bound Drugs (85%)5.5. Molecular Size (Daltons) Molecular Size (Daltons)

(200(200--400)400)6.6. Active TransportActive Transport

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MATERNAL FACTORSMATERNAL FACTORSPharmacodynamics Pharmacodynamics

1.1. Mammary epithelium may have drug Mammary epithelium may have drug --metabolizing capacitymetabolizing capacityg p yg p y

2.2. Milk volume is usually greatest in the Milk volume is usually greatest in the early morningearly morningearly morning early morning

3.3. Fat content of milk is usually highest in Fat content of milk is usually highest in the late morningthe late morning

44 Stage of breastfeeding is factorStage of breastfeeding is factor1515

4.4. Stage of breastfeeding is factorStage of breastfeeding is factor

Stage of BreastfeedingStage of BreastfeedingStage of BreastfeedingStage of Breastfeeding

Newborns feed every 1Newborns feed every 1--2 hours2 hoursNewborns feed every 1Newborns feed every 1 2 hours2 hoursColostrum (0Colostrum (0--3 days)3 days)T iti l Milk (4T iti l Milk (4 7 d )7 d )Transitional Milk (4Transitional Milk (4--7 days)7 days)Mature Milk (7Mature Milk (7--10 days)10 days)Alveolar Spaces (0Alveolar Spaces (0--7 days)7 days)

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INFANT FACTORSINFANT FACTORSPharmacodynamicsPharmacodynamics

1.1. Infant’s ability to absorb drugInfant’s ability to absorb drugInfant’s ability to detoxify and excreteInfant’s ability to detoxify and excrete2.2. Infant s ability to detoxify and excrete Infant s ability to detoxify and excrete the drugthe drug

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QUESTIONS TO ASK INDRUG / 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 goutcome and taking the drug?

6. What is the drug dosage schedule and how often do

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you nurse?

QUESTIONS TO ASK INDRUG / 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 know how to hand-express breast milk or11. 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?

2020

y y

STEPWISE APPROACH TO MINIMIZING INFANT DRUG EXPOSURE

1. Withhold the drug2. Try nondrug therapy3. Delay therapy4. Choose drugs that pass poorly into breast milk4. Choose drugs that pass poorly into breast milk5. Choose more breastfeeding compatible

dosage formsdosage forms

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STEPWISE APPROACH TO MINIMIZING STEPWISE APPROACH TO MINIMIZING INFANT DRUG EXPOSUREINFANT DRUG EXPOSUREINFANT DRUG EXPOSURE INFANT DRUG EXPOSURE (continued)(continued)

66 Choose an alternative route ofChoose an alternative route of66.. Choose an alternative route of Choose an alternative route of administrationadministration

77 Avoid nursing at times of peak drugAvoid nursing at times of peak drug7.7. Avoid nursing at times of peak drugAvoid nursing at times of peak drugconcentrations in milkconcentrations in milk

88 Administer drug immediately afterAdminister drug immediately after8.8. Administer drug immediately after Administer drug immediately after breastfeeding and / or before infant's breastfeeding and / or before infant's l t ll t llongest sleeplongest sleep

9.9. Temporarily withhold breastfeedingTemporarily withhold breastfeeding

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10. Discontinue breastfeeding (wean)10. Discontinue breastfeeding (wean)

CASE STUDYCASE STUDYCASE STUDYCASE STUDY

Mrs Maine a breastfeeding womanMrs Maine a breastfeeding womanMrs. Maine, a breastfeeding woman, Mrs. Maine, a breastfeeding woman, presents a prescription. She is presents a prescription. She is worried about taking this medicationworried about taking this medicationworried 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 knowrecommendation She wants to knowrecommendation. 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 Augustabreastfeeding her baby Augustabreastfeeding her baby, Augusta. breastfeeding her baby, Augusta.

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CASE STUDY (continued)CASE STUDY (continued)CASE STUDY (continued)CASE STUDY (continued)

After asking the mother several questionsAfter asking the mother several questionsAfter 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 tostates that she will be back in two hours tostates 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 whilethat the drug is usually safe to take whilethat the drug is usually safe to take while that the drug is usually safe to take while breastfeeding.breastfeeding.What questions should be asked theWhat questions should be asked theWhat questions should be asked the What questions should be asked the mother?mother?

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From the mother I was able to obtain theFrom the mother I was able to obtain theFrom 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 oldallergies Her baby is seven months oldallergies. 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 goingpounds (10 Kg) Breastfeeding is goingpounds (10 Kg). Breastfeeding is going pounds (10 Kg). Breastfeeding is going very well.very well.

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The prescription is for: XyboticThe prescription is for: XyboticThe 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).

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I am unable to find any AAPI am unable to find any AAPI 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?

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I run a computer search on Xybotic andI run a computer search on Xybotic andI 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 plasmaXybotic is 90 percent bound to plasmaXybotic 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 avolume of distribution of 1400 L has avolume 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 apeaks in plasma in one hour and has apeaks in plasma in one hour, and has a peaks in plasma in one hour, and has a halfhalf--life of four hours. life of four hours.

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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 0P k A id b tf di 0 2 h ft2 h ftPeak: Avoid breastfeeding 0Peak: Avoid breastfeeding 0--2 hours after 2 hours after

dose, if possibledose, if possibleH lfH lf Lif Sh ld t l t i b bLif Sh ld t l t i b bHalfHalf--Life: Should not accumulate in babyLife: Should not accumulate in baby

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I also am able to find a reference to oneI also am able to find a reference to oneI 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 oftook Xybotic an average of 0 01 mg oftook 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 milkbreast milkbreast milk.breast milk.Mother’s wt. adjusted dose: 40mg/Kg/dayMother’s wt. adjusted dose: 40mg/Kg/dayB b ’ t dj t d d 1 /K /dB b ’ t dj t d d 1 /K /dBaby’s wt. adjusted dose: 1 mg/Kg/dayBaby’s wt. adjusted dose: 1 mg/Kg/dayBaby/Mother Percentage = 2.5% (1/40)Baby/Mother Percentage = 2.5% (1/40)

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What recommendation would youWhat recommendation would youWhat 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 gy gwas not compatible with was not compatible with breastfeeding?breastfeeding?breastfeeding?breastfeeding?

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RecommendationRecommendationRecommendationRecommendation

OK to breastfeed while taking OK to breastfeed while taking OK to breastfeed while taking OK to breastfeed while taking XyboticXyboticObserve 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 drugtaking drug

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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 Approachthrough the Stepwise Approach

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CONSIDERATIONS: CONSIDERATIONS: P i i DP i i DPrescription DrugsPrescription Drugs

AnalgesicsAnalgesicsgg•• NonnarcoticNonnarcotic•• NarcoticNarcotic•• General and EpiduralGeneral and Epidural

AntiAnti--InfectivesInfectivesAntihistamines/Antihistamines/DecongestantsDecongestantsDecongestantsDecongestantsBronchodilatorsBronchodilatorsCorticosteroidsCorticosteroidsAntihypertensivesAntihypertensivesCardiac DrugsCardiac Drugs

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CONSIDERATIONS:CONSIDERATIONS:Prescription DrugsPrescription Drugs

AnticoagulantsAnticoagulantsggDiureticsDiureticsAntidiabeticsAntidiabeticsTh id/A tiTh id/A ti Th id DTh id DThyroid/AntiThyroid/Anti--Thyroid DrugsThyroid DrugsHormone ContraceptivesHormone ContraceptivesGastrointestinal DrugsGastrointestinal DrugsGastrointestinal DrugsGastrointestinal DrugsPsychotherapeutic DrugsPsychotherapeutic DrugsBenzodiazepinesBenzodiazepinesAntiepilepticsAntiepilepticsRadiopharmaceuticalsRadiopharmaceuticalsMiscellaneous DrugsMiscellaneous Drugs

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Miscellaneous DrugsMiscellaneous Drugs

SSRIsSSRIsSSRIsSSRIs

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)

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ADVERSE EFFECTSADVERSE 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%

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ADVERSE EFFECTSADVERSE EFFECTSADVERSE EFFECTSADVERSE EFFECTS

Psychotherapeutics (Antidepressants, Sedatives, Psychotherapeutics (Antidepressants, Sedatives, Antipsychotics): DrowsinessAntipsychotics): Drowsiness

Antimicrobials: DiarrheaAntimicrobials: DiarrheaAnticonvulsants: Drowsiness, sedation, poor feedingAnticonvulsants: Drowsiness, sedation, poor feedingAnticonvulsants: Drowsiness, sedation, poor feedingAnticonvulsants: Drowsiness, sedation, poor feedingAnalgesics (NSAIDs, Opioids): Drowsiness, sedationAnalgesics (NSAIDs, Opioids): Drowsiness, sedationHormonal Drugs: Decreased milk supply, volume, Hormonal Drugs: Decreased milk supply, volume,

quantityquantityquantityquantityIodides: Thyroid suppressionIodides: Thyroid suppressionCardiovascular Drugs: Weakness, hypotension, Cardiovascular Drugs: Weakness, hypotension,

bradycardiabradycardiabradycardiabradycardiaGIT Drugs: GIT upsetGIT Drugs: GIT upsetAntihistamines: Irritability, drowsinessAntihistamines: Irritability, drowsiness

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Chemotherapeutics: Toxic effects of treatmentChemotherapeutics: 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 , gAdverse drug reactions in breastfed infants: less Adverse drug reactions in breastfed infants: less than imagined. Clin Ped: 42 (4), 325than imagined. Clin Ped: 42 (4), 325--40: 200340: 2003

I S Bl j h A S h M lI S Bl j h A S h M lIto S, Blajchman A, Stephenson M, et al: Ito S, Blajchman A, Stephenson M, et al: Prospective followProspective follow--up of adverse reactions in up of adverse reactions in breastbreast--fed infants exposed to maternalfed infants exposed to maternalbreastbreast fed infants exposed to maternal fed infants exposed to maternal medication. Am J Obstet Gynecol: 168 (5), medication. Am J Obstet Gynecol: 168 (5), 13931393--9: 19939: 1993

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Codeine Rapid MetabolizersCodeine Rapid MetabolizersCodeine Rapid MetabolizersCodeine Rapid Metabolizers

1313--day breastfed baby dies from day breastfed baby dies from 1313 day breastfed baby dies from day breastfed baby dies from morphine overdose in breast milk in morphine overdose in breast milk in mother taking codeinemother taking codeinemother taking codeinemother taking codeineHow did that ever happen?How did that ever happen?

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ABM Clinical Protocol #15ABM Clinical Protocol #15ABM Clinical Protocol #15ABM Clinical Protocol #15Academy 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 MotherMotherAnne Montgomery, Thomas W. Hale, and The Anne Montgomery, Thomas W. Hale, and The Academy of Breastfeeding Medicine Protocol Academy of Breastfeeding Medicine Protocol CommitteeCommitteeCommitteeCommitteeReprint Requests: [email protected] Requests: [email protected]://www.bfmed.org/Resources/http://www.bfmed.org/Resources/p // g/ /p // g/ /

Protocols.aspxProtocols.aspx

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CONSIDERATIONS: CONSIDERATIONS: OTC M di iOTC M di iOTC MedicationsOTC Medications

AnalgesicsAnalgesics AntiAnti--Diarrheal PreparationsDiarrheal PreparationsAnalgesicsAnalgesicsCough, Cold, and Allergy Cough, Cold, and Allergy PreparationsPreparationsC h d C ld LC h d C ld L

AntiAnti Diarrheal PreparationsDiarrheal PreparationsNausea and Vomiting / Motion Nausea and Vomiting / Motion Sickness PreparationsSickness PreparationsHemorrhoidal PreparationsHemorrhoidal PreparationsCough and Cold Lozenges Cough and Cold Lozenges

and Spraysand SpraysNasal PreparationsNasal Preparations

Hemorrhoidal PreparationsHemorrhoidal PreparationsSleep PreparationsSleep PreparationsStimulantsStimulantsA tit S t P d tA tit S t P d t

ppAsthma PreparationsAsthma PreparationsAntacids and Digestive AidsAntacids and Digestive Aids

Appetite Suppressant ProductsAppetite Suppressant ProductsInsulin PreparationsInsulin PreparationsArtificial SweetenersArtificial Sweeteners

Laxatives / Stool SoftenersLaxatives / Stool Softeners Miscellaneous OTCsMiscellaneous OTCs

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OTC OTC BREASTFEEDING COUNSELINGBREASTFEEDING COUNSELINGBREASTFEEDING COUNSELING BREASTFEEDING COUNSELING

GUIDELINESGUIDELINESAvoid taking OTC medications for which safer products Avoid taking OTC medications for which safer products g pg pare 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 willOTC that has the one or two specific ingredients that willOTC 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).

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OTC OTC BREASTFEEDING COUNSELINGBREASTFEEDING COUNSELINGBREASTFEEDING COUNSELING BREASTFEEDING COUNSELING

GUIDELINESGUIDELINESAvoid taking extra strength forms of OTC medications Avoid taking extra strength forms of OTC medications g gg 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 longAvoid taking long--acting OTC medications (there is noacting OTC medications (there is noAvoid taking longAvoid 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 ldIf ibl ith i ti d th th h ldIf 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.

4747

CONSIDERATIONS: CONSIDERATIONS: H b l (M j G l )H b l (M j G l )Herbals (Major Galactogogues)Herbals (Major Galactogogues)Chaste TreeChaste TreeChaste TreeChaste TreeFennelFennelFenugreekFenugreekFenugreekFenugreekGarlicGarlicGoat's RueGoat's RueMilk Thistle / Blessed ThistleMilk Thistle / Blessed Thistle

4848

CONSIDERATIONS: CONSIDERATIONS: H b l (Mi G l )H b l (Mi G l )Herbals (Minor Galactogogues)Herbals (Minor Galactogogues)AniseAnise MarshmallowMarshmallowAniseAniseBorageBorageAlfalfaAlfalfa

MarshmallowMarshmallowNettleNettleHopsHopsAlfalfaAlfalfa

CarawayCarawayCorianderCoriander

HopsHopsOat StrawOat StrawRed CloverRed CloverCorianderCoriander

DandelionDandelionDillDill

Red CloverRed CloverRed RaspberryRed RaspberryVervainVervainDillDill VervainVervain

4949

CONSIDERATIONS: CONSIDERATIONS: H b lH b lHerbalsHerbals

Analgesics Analgesics Bugleweed, Comfrey Bugleweed, Comfrey

Headache (Migraine) AgentsHeadache (Migraine) AgentsFeverfewFeverfewFeverfewFeverfew

AntiAnti--Anxiety Agents Anxiety Agents Indian Snakeroot, Kava Kava, Passionflower, Indian Snakeroot, Kava Kava, Passionflower, St John’s Wort ValerianSt John’s Wort ValerianSt. John s Wort, Valerian St. John s Wort, Valerian

StimulantsStimulantsGinseng Root, Siberian Ginseng, Ginkgo Biloba, Ginseng Root, Siberian Ginseng, Ginkgo Biloba, A li R t / D Q iA li R t / D Q iAngelica Root / Dong QuaiAngelica Root / Dong Quai

Sleep PreparationsSleep PreparationsMelatoninMelatonin

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CONSIDERATIONS: CONSIDERATIONS: H b lH b lHerbalsHerbals

Cough, Cold, and Allergy ProductsCough, Cold, and Allergy ProductsColtsfoot, Echinacea, Elder FlowerColtsfoot, Echinacea, Elder Flower

Gastrointestinal AgentsGastrointestinal AgentsGastrointestinal AgentsGastrointestinal AgentsAloe, Buckthorn, Cascara Sagrada, Chamomile, Aloe, Buckthorn, Cascara Sagrada, Chamomile, Flaxseed, Licorice, Psyllium Seed, Rhubarb, SennaFlaxseed, Licorice, Psyllium Seed, Rhubarb, Senna

Nausea and Vomiting PreparationsNausea and Vomiting PreparationsNausea and Vomiting PreparationsNausea and Vomiting PreparationsGingerGinger

Lipid Lowering AgentsLipid Lowering AgentsS L ithiS L ithiSoy LecithinSoy Lecithin

Urinary Tract PreparationsUrinary Tract PreparationsGoldenrod, Petasites, Uva UrsiGoldenrod, Petasites, Uva Ursi

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CONSIDERATIONS: CONSIDERATIONS: R i l DR i l DRecreational DrugsRecreational Drugs

Amphetamine / MethylphenidateAmphetamine / Methylphenidatep y pp y p

MarijuanaMarijuana

CocaineCocaineCocaineCocaine

PhencyclidinePhencyclidine

NarcoticsNarcotics

CaffeineCaffeine

AlcoholAlcohol

NicotineNicotine5252

NicotineNicotine

RECREATIONAL DRUGSRECREATIONAL DRUGSRECREATIONAL DRUGSRECREATIONAL DRUGS

From both a philosophical and scientificFrom both a philosophical and scientificFrom both a philosophical and scientificFrom both a philosophical and scientificviewpoint, recreational drugs of abuse viewpoint, recreational drugs of abuse should beshould be contraindicated duringcontraindicated duringshould beshould be contraindicated during contraindicated during breastfeedingbreastfeeding as they are hazardous, not as they are hazardous, not only to the nursling but to the mother asonly to the nursling but to the mother asonly to the nursling, but to the mother as only to the nursling, but to the mother as well. well.

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FINAL CONSIDERATIONSFINAL CONSIDERATIONS• Only essential drugs should be taken by the

i th Sh h ld bnursing mother. She should be knowledgeable of and be encouraged to report any adverse effectsany 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

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nurse, in most cases, drugs that have safe therapeutic levels can be given

Courtesy of NIHCourtesy of NIH 5555

JAPhA ArticleJAPhA ArticleJAPhA ArticleJAPhA 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 BreastBreast--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: 86Association. 52: 86--94 94 (January/February) 2012(January/February) 2012(January/February) 2012.(January/February) 2012.

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PUBLICATIONSPUBLICATIONSPUBLICATIONSPUBLICATIONS

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: 1293: 129 132 (June) 2011132 (June) 20113: 1293: 129--132 (June) 2011.132 (June) 2011.

PUBLICATIONSPUBLICATIONSPUBLICATIONSPUBLICATIONSNice 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 BreastMedications 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 IPart I. . J l f Ph T h lJ l f Ph T h l 20 17 20 17 27 27 Journal of Pharmacy TechnologyJournal of Pharmacy Technology, 20: 17, 20: 17--27 27 (January/February) 2004.(January/February) 2004.

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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 BreastMedications and Breast--Feeding: A Guide Feeding: A Guide Medications and BreastMedications 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 IIPart II. . Journal of Pharmacy TechnologyJournal of Pharmacy Technology, 20: 85, 20: 85--95 95 (March/April) 2004(March/April) 2004..

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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 BreastMedications and Breast--Feeding: A Guide for Feeding: A Guide for ggPharmacists, Pharmacy Technicians, and Pharmacists, Pharmacy Technicians, and Other Healthcare Professionals, Other Healthcare Professionals, Part IIIPart III. . Journal of Pharmacy TechnologyJournal of Pharmacy Technology, 20: 165, 20: 165--177 177 (May/June) 2004.(May/June) 2004.

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PUBLICATIONSPUBLICATIONSPUBLICATIONSPUBLICATIONSNice FJ: OverNice FJ: Over--thethe--Counter Medication Use During Counter Medication Use During Breastfeeding Breastfeeding Pharmacy TimesPharmacy Times 67:46 48 67:46 48--49 49 Breastfeeding. Breastfeeding. Pharmacy TimesPharmacy 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 Overand Over--thethe--Counter Medications. Counter Medications. Journal of Journal of Human LactationHuman 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 JournalBirth Issues Journal 9:77 9:77--84 84 While Breastfeeding? While Breastfeeding? Birth Issues JournalBirth Issues Journal, 9:77, 9:77 84 84 (September/October) 2000.(September/October) 2000.

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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. PharmacistU.S. Pharmacist, 25: 28, 31, 25: 28, 31--32, 24, 4132, 24, 41--42, 4542, 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 TimesPharmacy Times, 65: 52, 55, 65: 52, 55--58, 6158, 61--62, 6462, 64--66, 68, 70, 72 (September) 1999.66, 68, 70, 72 (September) 1999.

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Thank you for your participationThank you for your participationThank you for your participationThank you for your participation

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Medications and Breastfeeding

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