Drugs In Lactation

DRUGS IN

LACTATION

Topics I. Facts about drugs in lactation II. Classification of drugs in lactation III. Effects of drugs on the Mother & Baby IV. Measures to Minimize Effect of Maternal medication

II. Classification of Drugs for Breastfeeding (As to Recommendation during Lactation)

I. FACTS ABOUT DRUGS IN LACTATION 1. Most drugs pass through breastmilk. 2. 1% less of maternal dose appear in breastmilk. 3. Few drugs are contraindicated. 4. Some drugs cause side effects on the baby. 5. Baby’s exposure to a drug can be minimized.

I. COMPATIBLE WITH BREASTFEEDING Safe and No Contraindication Exception

1. Anesthetics

• • •

2. Antihistaminics

• Diphenhydramine Hcl • Loratadine

3. Hypnosedative

• Midazolam • Diazepam

Sevoflurane Ketamine Bupivacaine Hcl

compatible

Exception

4. Muscle Relaxant

• Suxamethonium • Vecuronium

5. Anti-secretory • Cimetidine GIT • Ranitidine

6. Analgesic /Antipyretics

• • •

Paracetamol Acetaminophen NSAid (1st generation)

Dantrolene

Omeprazole Misoprostol

NSAID 2nd Generation Celecoxib

compatible

Exception

7. Steroid

8. Antibacterial

9. Antihypertensive

• Dexamethesone (single) • Hydrocortisone (single) • Erythromycin • Amoxicillin • Ampicillin • Cloxacillin • Captopril (capoten) • Methyldopa (Aldomet)

compatible

compatible

Exception

10. Antidysrrhythmia

• Lidocaine Hcl • Quinidine

11. Cardiac Glycoside • Digitoxin • Digoxin compatible 12. Anti-asthma /Anti- • Salbutamol oxytoxic 13. Antitussives

• Codeine (single dose • Ammonium Chloride

Amiodarone

compatible

Exception

14. Oxytocin

• Oxytocin (short term)

15. Diuretics

• • •

16. Dermatological Antifungal

Mannitol Spirinolactone Selenium Sulfide

17. Opthalmological Antiglaucoma

• Acetazolamide

18. Cytotoxic Drugs

• Calcium Folinate

compatible

Exception

19. Immunologicals Immunoglobuline

Vaccine 20. Vitamins

21. Antithyroid

• Antitetanus Immunoglobuline • Diptheria Antitoxin • Smallpox • BCG vaccine • Measles • Ascorbic in usual dose • Thiamine • Levothyroxine

RECOMMENDATION:

Take the drugs and continue to breastfeed

II. Compatible with Breastfeeding but Monitor Infant for Side Effects (minor side effects but rare) Side Effects 1. Anticholinergic

• AtSO4

2. Antiemetics

• Metoclopramide

3. Analgesics

• Pethidine in occasional dose • Morphine in occasional dose

• Drying of secretion • Increase temperature

Compatible but monitor

Side Effects 4. Anti-TB Drugs

• • •

5. Vitamin

• Ascorbic acid (large dose

Hemolysis Jaundice

6. Antibacterial

• Gentamycin

Thrush & diarrhea

7. Antiasthma

• Aminophylline

Irritability

8. Antiangina

• Verapamil

Rifampicin Streptomycin Ethambutol

Jaundice

Compatible but monitor

Side Effects

9. Antihypertensive

• Hydralazine (apresoline) • Nifedipine

10. Diagnostic Agent • Propyliodine 11. Anticonvulsant

Hypothyroidism

• Phenobarbital • Drowsiness (luminal) • Poor suckling / weight gain

12. Analgesic /Antipyretic

• MgSO4 • ASA (occasional dose)

RECOMMENDATIONS: Notify mother…. If + side effects  stop taking the drugs and find alternative If mother cannot stop taking the drugs  stop breastfeeding and feed with pasteurized milk Continue milk expression

III. Avoid if Possible, monitor for side effects

(repeated doses  serious side effects) 1. Antihistaminic

• Chlorphenamine

2. Hypnosedative

• Diazepam

• Drowsiness • Irritability • Drowsiness

3. Opioid Analgesic

• Pethidine • Morphine

• Apnea • Bradycardia

4. Antibiotics

• Tetracycline

• Teeth staining • Hemolysis • Jaundice

• Chlorampenicol

Avoid if possible

5. Disinfectant

• Povidone Iodine (Topical)

• Hypothyroidism

6. Anti-angina

• Atenolol

• Bradycardia • Hypotension • Cyanosis

• Chlorpromazine

• Drowsiness • Restlessness • Weakness • Poor muscle tone

/ Antihypertensive

7. Psychotherapeutic

• Lithium

8. Antibacterial

• Metronidazole

Avoid if possible

9. Antitussives

• Apnea • Codeine in repeated doses • Bradycardia • Cyanosis

10. Ethanol Intake

• Chronic use of alcohol

• Drowsiness • Poor growth • Weakness

11. Caffeine

• Excessive dosage

• Wakefulness • Hyperactivity • Poor sleeping pattern • Irritability

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-cholinergic

• AtSO4 (repeated doses

2. Anti-gout

• Colchicine

3. Diuretics

• Furosemide • Hydrochlorothia-zide

4. Oxytocin

• Ergometrine (repeated doses) • Oxytocin (prolonged use)

(May Inhibit Lactation)

5. Hormonal Contraceptives

• • •

6. Anti-parkinsonism

• Carbidopa • Levodopa

7. Excess Nicotine Intake

• Cigarettes more than 20/day

8. Anti-migraine

• Ergot alkaloid • Ergot ergotamine

Ethinylestradiol Levonorgestril Ethinyl estradiol + Norethisterone

RECOMMENDATION: Frequent Suckling of the Breast

V. Avoid (Dangerous Side Effects on the Baby) 1. Anti-neoplastic

• Cytotoxic – Cisplatin – Vincristine – Methotrexate • Immunosuppresive – Ciclosporin – Azathioprine

AVOID

2. Radiopharmaceutical Anti-thyroid Cause damage to - iodine 131 or Na iodide nursing infant (Na 131) thyroid Increase risk Elimination of Radio-iodine from of thyroid CA the milk Na 131 - 14 days Iodine 123 - 36 hours 125 - 12 days

AVOID

3. Hallucinogenic

• Marijuana • LSD • PCP (Phencyclidine)

• Irritability • Poor feeding

4. Anorexant / Appetite, suppresant

• Phentermine • CNS stimulation • Amphetamine may occur in nursing infant

5. Anti-lipemic

• Simvastatin • Fluvastatin

RECOMMENDATION: Stop breastfeeding until treatment is completed

Is there a drug that is absolutely safe?

EFFECTS OF DRUGS TO THE MOTHER 1. Estrogen /Thiazide

• Suppress lactation

2. Rifampicin (Orange)

• Colors breastmilk

3. Metronidazole

Flavors breast milk • (Bitter taste) Onion, Garlic • (Radiographic Contrast Media) metalic taste

Iothalamate 4. Metoclopramide

• Increase lactation

5. Nicotine

• Decrease milk production

EFFECTS OF DRUGS TO THE BABY

1. Diazepam / Phenobarbital 2. Chlorphenamine / Theophylline

• • • •

Lethargy Drowsiness Sedation Irritability

3. Indomethacin

• Convulsion

4. Phenobarbital / Carbamazepine

• Poor suckling • Poor weight gain

EFFECTS OF DRUGS TO THE BABY

5. Clindamycin

• Bloody Diarrhea

6. Gentamycin / Streptomycin

• Diarrhea /Thrush

7. AtSO4

• Fever • Drying of secretion • Rashes

8. Penicillin 9. Anti-TB /Ascorbic Acid (large doses) / Chloramphenicol

• Jaundice

EFFECTS OF DRUGS TO THE BABY

10. 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 BABY

• Hypothyroidism 14. K Iodide / Povidone Iodine 15. Caffeine

• • • •

16. Tetracycline

• Staining teeth

17. Morphine / Pethidine

• Apnea • Bradycardia

18. Morphine

• Urinary Retention

Hyperactivity Wakefulness Slow excretion Poor sleeping pattern

MEASURES TO MINIMIZE EFFECT OF MATERNAL MEDICATION

• Avoid long acting forms of drug. • Schedule the dose • Choose the safest drug • Watch out for signs and symptoms • If a drug may present a risk to the infant measure blood concentrations.

Medicines in Lactation judgement 1. Requirement careful assessment of Risk vs. Harm indication 2. Usage proven benefits

The use of medicine in lactation • Requires a balance of judgement and careful assessment of the risk of not giving against any possible potential harm from its use • Medicines should only be used in lactation if it is clearly indicated and of proven benefits to the mother and baby.

Salamat Po !