Medication in lactation

Ph. Halima Alzadjali

  Objectives
 Background
 Advantages of breastfeeding
 Breastfeeding & medication
 Factors Influencing Drug Safety
 Drugs in Lactation – Factors to consider
 Medications Risk Categories in lactation
 Contraindicated Drugs
 Case studies
 Conclusion
 Background
 90% of women are prescribed medication in first week of
postpartum

 Almost all medication appears into human milk.

 Mothers worry about the effect of medication on the infant.

 Leads to: non compliance, weaning, avoidance of breastfeeding

 Most drugs pass in very small amounts, usually less than
1% of the maternal dose.

 Very few drugs are contraindicated for nursing mothers.

 Advantages of Breastfeeding
Mother
 Reduce the risk of fracture/osteoporosis
 Reduce the risk of cancer
 Emotional
 Convenience
 Less cost
 Advantages of Breastfeeding
baby
 Reduce risk of infection
 Reduce risk of SIDS
 Reduce risk of many immune mediated diseases
 Emotional/Bonding
 Breastfeeding & Medication
Breastfeeding should be discouraged only when
there is substantial evidence that :

The drug taken by the mother will be harmful to

infant

No therapeutic equivalent can be given

 Factors Influencing Drug Safety
Drug Factors

• Diffusion / active • Protein binding

transport • Half life
• Plasma level • Oral bioavailability
• Lipid solubility
• Drug PH
• Molecular weight
 Factors Influencing Drug Safety

Infant Factors Maternal Factors

• Age • Dose
• Body weight • Route of administration
• Health status • Health status
 Drugs in Lactation – Factors to consider
 Choose a route of admin. which minimizes maternal drug level :
topical, inhalation.

 Choose medications :- shortest T1/2 , highest protein binding

ability, poorest oral absorption, lowest lipid solubility, well-
studied in infants.

 Use the lowest effective dose & for the shortest time.

 To minimize drug level in the milk - administer the drug

immediately after the infant feed.
 Drugs in Lactation – Factors to consider
 In case of no available alternative, medication is best taken
just prior to the longest sleep of the infant.

 Infants should be monitored for AE : feeding, sedation,

irritability, rash, etc.

 For some medications with potential harm, temporary

suspension of breastfeeding may be necessary. (Eg. Contrast
solution before MRI )
Medications Risk Categories in lactation

• L1 Safest
• L2 Safer
• L3 Moderately safe
• L4 Possibly hazardous
• L5 Contraindicated
 L1 Safest: Taken by large No. of BF mothers
without any observed SE

 L2 Safer: Studied on limited No. of BF mothers

without any observed SE
 L3 Moderate safe: No controlled studies/ controlled
studies showed minimum non threatening AE

 L4 Possible hazardous: There are evidences of risk

to BF infant / to breast milk production

 L5 Contraindicated : Studies showed signs/ high

risk to infants.
Contraindicated
Drugs
 Contraindicated Drugs
Some drugs contraindicated during lactation are mentioned
below:
 Anti-cancer drugs - diarrhea and reduced immunity in the infant.
 Chloramphenicol – diarrhea, bone marrow suppression and gray
baby syndrome.
 Retinoids - Very lipid soluble, mutagenic & carcinogenic in animals
 Tetracycline -Staining immature teeth, change in epiphyseal bone
growth.
 Aspirin in large doses – May cause bleeding or Reye’s syndrome in
the infant
 Contraindicated Drugs
 Estrogens - May reduce milk production and cause
increase breast size in male child

 Ergotamine – cause ergotism and suppress lactation

 Gold salts -Facial edema.

 Lithium -Severe rash.

 Medication used to Increase Milk Supply
in lactating mother
 Metoclopermide 10mg:
 Dose :10mg twice or 3 times per a day for 1-2 week

 Domperidone 10mg
 Dose :10mg twice or 3 times per a day for 1-2 week
 Can be given 4 times
 (contraindicated in heart disease patient)
 Medication inhibit milk supply in lactating
mother
 Cabergolin 250mcg
 Dose :250 mcg twice a day for 2 days
 Bromocriptin 2.5mg
 Dose :2.5mg once a day for 2-3 days or
 2.5 mg twice per a day for 2 weeks
Patient: S.S , 36years old, Delivered by LSCS
High fever due to UTI
Post partum psychosis attack

Ceftrixone injection 2 g OD
Haloperidol injection 5mg STAT
Pharmacist Advice :
To continue with Haloperidol tab 1.5 mg BID (L3)
T half :12-38hrs Tmax:2-6hrs
Advise : to pump and dump for 2-3hrs
But watch the baby for any sedation effect.
1
Patient : R.A , 35 years old, Delivered by LSCS
Case of Multiple Sclerosis (MS) 2
She has to continue with her neurological medication
Aubajio (teriflunomide)? (L5)
Pharmacist Advice :
Aubagio is associated with potentially serious side effects,
including liver problems and infections. Because there is the
potential that the drug could pass through breast milk and cause
these and other problems in a nursing child.
Outweigh the Benefit –Risk Ratio
Patient: Z.H , 35years old, Delivered by LSCS
- Severe neck pain & headache on day 2
3

Pain was not controlled:

Rx Tramadol inj 100mg TID for 1day (L2)
Pharmacist advice:
To change Rx to:
Tramadol 50mg TID for 2days
Patient: S.M , 26years old, Delivered by SVD
Patient had wound gaping 4

Culture showed scanty growth of MRSA

Vancomycin inj. 1g BID

Pharmacist advice:
Local antibiotics will be enough & effective

Outcomes
 Patient was on fucidic acid cream

 Patient was responding & wound improved

 Patient was discharged

 Conclusion
 Avoid unnecessary drug use and limit use of OTC products
 Assess the benefit/risk ratio for both mother and infant
 Avoid use of drugs known to cause serious toxicity in adults or
children
 Drugs licensed for use in infants do not generally pose a hazard
 Neonates (esp. premature infants) are at greater risk from
exposure to drugs via breast milk
 Route of administration (minimum amount of drug to the infant)
 Avoid long-acting preparations
 Monitor Infants exposed to drugs via breast milk for unusual
signs/symptoms
 Avoid new drugs if possible
 Pharmacy is
always available to
help
 References
 Hale, Thomas. Medications and Mothers’ Milk, 14th
ed. Amarillo, TX: Pharmasoft, 2010
www.ibreastfeeding.com

 LactMed on ToxNet (AAP document)

 www.ibreastfeeding.com