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Information on this subject has been updated. Read the most recent information. Many mothers are required to use drugs during breastfeeding. Almost all drugs transfer into breast milk and this may carry a risk to a breastfed infant. Factors such as the dose received via breast milk, and the pharmacokinetics and effect of the drug in the infant need to be taken into consideration.
Problems should not be overstated however, as many drugs are considered 'safe' during breastfeeding. Nearly all drugs transfer into breast milk to some extent. Notable exceptions are heparin and insulin which are too large to cross biological membranes. The infant almost invariably receives no benefit from this form of exposure and is considered to be an 'innocent bystander'.
Drug transfer from maternal plasma to milk is, with rare exceptions, by passive diffusion across biological membranes. Transfer is greatest in the presence of low maternal plasma protein binding and high lipid solubility. In addition, milk is slightly more acidic than plasma pH of milk is approximately 7. Milk composition varies within and between feeds and this may also affect transfer of drugs into breast milk.
For example, milk at the end of a feed hindmilk contains considerably more fat than foremilk and may concentrate fat-soluble drugs. The volume of milk ingested by infants is commonly estimated as 0. As a general rule, maternal use of topical preparations such as creams, nasal sprays or inhalers would be expected Searching for lactating woman short term anr carry less risk to a breastfed infant than systemically administered drugs.
This is due to lower maternal concentrations and therefore lower transfer into breast milk. However, the risk to the infant must be considered in relation to the toxicity of the drug used, the dosage regimen and the area of application. For example, use of corticosteroids nasal sprays or inhalers in standard doses would be considered compatible with breastfeeding.
Other factors to consider in conjunction with the infant's dose include the pharmacokinetics of the drug in the infant. Generally, drugs that are poorly absorbed or have high first-pass metabolism are less likely to be problematical during breastfeeding. For example, gentamicin is highly hydrophilic and is very poorly absorbed when administered orally. Should any gentamicin be ingested via breast milk, it is unlikely to be absorbed.
Drug clearance in the infant is a particularly important consideration and premature infants have a severely limited ability to clear drugs. Within a few days of delivery, term infants have glomerular filtration rates approximately one-third of adult values after adjusting for difference in body surface area, and premature infants have even more impaired clearance see Table 1. Generally, adult glomerular filtration rates adjusted for the difference in surface area are attained by five to six months of age.
Metabolic processes such as phase 1 oxidation and phase 2 glucuronidation are also impaired in the neonate. Drugs subject to high first-pass metabolism may have higher oral availability in premature or term infants due to impaired ability to metabolise on first-pass. Adult metabolic capacity is attained towards the latter part of the infant's first year of life.
The following table is useful for estimating infant clearance. The overall risk of a drug to a breastfed infant depends on the concentration in the infant's blood and the effects of the drug in the infant. If, after assessment of the risks and benefits, the decision is made to breastfeed while the mother is using a drug, the infant should be monitored for adverse effects such as failure to thrive, irritability and sedation. However, it is difficult to identify adverse reactions occurring in neonates. Feeding immediately prior to a dose may help to minimise infant exposure as concentrations in milk are likely to be lowest towards the end of a dosing interval.
However, for some drugs, milk concentrations lag behind plasma concentrations. For drugs that are not considered safe in breastfeeding, breast milk may be expressed and discarded for the treatment duration. Breastfeeding may be d after the drug has been eliminated from the maternal blood stream. A discussion of the safety of the more commonly used drugs is provided below. The data must be assessed in conjunction with information on the maternal dose and therefore probable maternal concentrations, the age of the infant and their likely ability to eliminate the drug.
Analgesics such as paracetamol, ibuprofen, naproxen and codeine are considered to be 'safe', due to low transfer into breast milk and few problems with extensive usage. Transfer of aspirin into breast milk appears to be low but it is best avoided due to the theoretical risk of Reye's syndrome.
Sumatriptan has a short half-life of approximately two hours and infant exposure can be almost completely avoided by expressing and discarding breast milk for approximately eight hours after dosing. Limited data on tramadol suggest low transfer into breast milk although where possible, it would be preferable to use agents which are more established such as codeine and paracetamol. Morphine is usually considered 'safe' because of low transfer into milk, and high first-pass metabolism. There does not appear to be any data on the transfer of mebendazole or pyrantel embonate into human breast milk although these agents are generally considered to be 'safe' due to poor absorption from the gastrointestinal tract.
Antibiotics such as penicillins, cephalosporins and macrolides are considered to be compatible with breastfeeding although there are theoretical risks of alterations to infant bowel flora and allergic sensitisation.
The safety of metronidazole is controversial due to the possibility of high transfer into breast milk. If breastfeeding is to be withheld, the mother should be encouraged to continue to express breast milk while on the antibiotic course but to discard the milk. This will help to maintain lactation and enable the mother to breastfeeding at the end of the course. The transfer of tetracyclines into breast milk is low but they are usually avoided due to the possible risks of inhibiting bone growth or causing dental staining.
Fluoroquinolones should also be avoided in breastfeeding as they have been reported to cause arthropathies in immature animals. Sulphonamides such as sulphamethoxazole are unlikely to be problematical in most situations but are best avoided in infants with hyperbilirubinaemia or glucosephosphate dehydrogenase deficiency.
Heparins unfractionated and low molecular weight are considered 'safe' since these agents have a large molecular weight and do not cross into breast milk to a ificant extent. They are also poorly absorbed. Warfarin is also considered to be compatible with breastfeeding as Searching for lactating woman short term anr is low, and adverse effects and changes in prothrombin time have not been detected in breastfed infants.
However, it would be prudent to monitor the infant's prothrombin time during treatment. Carbamazepine, phenytoin and sodium valproate are generally considered to be compatible with breastfeeding although the infant should be observed for evidence of central nervous system depression. Available data on the safety of lamotrigine in breastfeeding suggest that transfer into breast milk may be considerable and therapeutic concentrations have been detected in breastfed infants.
There are insufficient published data to comment on the safety of gabapentin in breastfeeding. Selective serotonin reuptake inhibitors SSRIs transfer into breast milk to varying extents. Based on these data, paroxetine is the preferred SSRI in breastfeeding women.
Most tricyclic antidepressants are considered to be compatible with breastfeeding due to low transfer into breast milk and this is supported by extensive usage data. Moclobemide has low-transfer into breast milk and is considered compatible with breastfeeding. Agents such as promethazine, dexchlorpheniramine and diphenhydramine are considered to be safe through extensive usage, although it would be prudent to monitor for evidence of sedation or irritability in the infant.
There is less data on the non-sedating antihistamines, although loratadine and fexofenadine are likely to be safe due to low transfer into milk. Sporadic use of benzodiazepines with a short plasma half-life such as midazolam and temazepam is unlikely to be problematical due to low quantities transferred into breast milk. Agents with a long half-life such as diazepam may accumulate in the infant with prolonged exposure and may be associated with lethargy, poor suckling and reduced weight gain.
However, topical decongestant nasal sprays or drops are usually preferred due to lower infant exposure. In addition most have relatively high infant doses. Alcohol consumption should be minimised during lactation e. Nicotine has been detected in the plasma of breastfed infants, and smoking is best avoided by breastfeeding mothers.
The use of nicotine replacement therapy e. However, as a general rule, the short-term use of nicotine replacement therapy is far preferable than continued smoking. Drugs can affect milk secretion or composition by affecting factors such as mammary gland development, milk secretion and hormonal regulation of lactation. Prolactin is necessary for human milk secretion and may be affected by drug use. Dopamine agonists such as cabergoline reduce prolactin and are sometimes used therapeutically to stop lactation. Dopamine antagonists such as metoclopramide and most antipsychotics may increase prolactin see article on Hyperprolactinaemia With Antipsychotics and milk production.
Other drugs that have been associated with causing hyperprolactinaemia include SSRIs and opioids. Interpretation of these requires an understanding of the limitations associated with published data, such as the availability of only single pairs of plasma and milk concentrations. Infant clearance related to post-conceptual age should always be considered. E-mail: sharon. Drugs in human milk.
Clinical pharmacokinetic considerations. Clinical Pharmacokinetics ; Drugs and human lactation. Amsterdam: Elsevier, Drug distribution in human milk. Australian Prescriber ;20 2 Avery's Drug Treatment. Auckland: Adis International Ltd, Avoid in favour of safer alternatives with lower potential for side effects. May accumulate in milk due to active transport. Probably safe when restricted to sporadic doses or a single dose at night-time. Exposure limited by low oral availability in term infants. Expressing for 8 hours post-dose will almost completely avoid exposure.
Considered compatible with breastfeeding due to low transfer and low oral availability. Considered safe. Low transfer into milk. Third generation cephalosporins have greater potential to alter bowel flora. Avoid tetracyclines where feasible due to the possible risks of dental staining and adverse effects on bone development. Controversial as exposure may be high. With high doses consider expressing and discarding milk.
Avoid suphaemethoxazole in infants with hyperbilirubinaemia and G6PD deficiency. Probably safe. Searching for lactating woman short term anr changes in prothrombin times detected in breastfeeding infants. Monitor prothrombin time. Concentrations in breastfed infants have been consistent with those expected to produce clinical effect. Best to avoid. Observe for sedation, poor suckling. One report of methaemoglobinaemia, poor suckling and sedation. Considered safe at low doses.
High doses may increase the risk of hepatitis. Negligible or no concentrations detected in breastfed infants.Searching for lactating woman short term anr
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