Breastfeeding and Medication

Introduction

Over the years, far too many women have been wrongly told they had to stop breastfeeding because they must take a particular drug. The decision about continuing breastfeeding when the mother takes a drug, for example, is far more involved than whether the baby will get any of the drug in the milk. It also involves taking into consideration the risks of not breastfeeding, for the mother, the baby and the family, as well as society. And there are plenty of risks in not breastfeeding, so the question essentially boils down to: Does the addition of a small amount of medication to the mother’s milk make breastfeeding more hazardous than formula feeding? The answer is almost never. Breastfeeding with a little drug in the milk is almost always safer. In other words, being careful means continuing breastfeeding, not stopping.

Remember that stopping breastfeeding for a week may result in permanent weaning since the baby may then not take the breast again. On the other hand, it should be taken into consideration that some babies may refuse to take the bottle completely, so that the advice to stop is not only incorrect, but often impractical as well. On top of that it is easy to advise the mother to pump her milk while the baby is not breastfeeding, but this is not always easy in practice and the mother may end up painfully engorged.

Breastfeeding and Maternal Medications

Most drugs appear in the milk, but usually only in tiny amounts. Although a very few drugs may still cause problems for infants even in tiny doses, this is not the case for the vast majority. Breastfeeding mothers who are told they must stop breastfeeding because of a certain drug should ask the physician to make sure of this by checking with reliable sources. Note that the CPS (in Canada) and the PDR (in the USA) are not reliable sources of information about drugs and breastfeeding. These “resources” are merely a compilation of the information provided by the drug manufacturers who are more interested in their medical legal liability than the interests of the mother and baby. Their policy is essentially “We can’t be held responsible if the mother interrupts breastfeeding”. Or the mother should ask the physician to prescribe an alternate medication that is acceptable during breastfeeding. In this day and age, it should not be a problem to find a safe alternative. If the prescribing physician is not flexible, the mother should seek another opinion, but not stop breastfeeding.

Why do most drugs appear in the milk in only small amounts? Because what gets into the milk depends on the concentration in the mother’s blood, and the concentration in the mother’s blood is often measured in micro- or even nano-grams per millilitre (millionths or billionths of a gram), whereas the mother takes the drug in milligrams (thousandths of grams) or even grams. Furthermore, not all the drug in the mother’s blood can get into the milk. Only the drug that is not attached to protein in the mother’s blood can get into the milk. Many drugs are almost completely attached to protein in the mother’s blood. Thus, the baby isnot getting amounts of drug similar to the mother’s intake, but almost always, much less on a weight basis. For example, in one study with the antidepressant paroxetine (Paxil), the mother got over 300 micrograms per kg per day, whereas the baby got about 1 microgram per kg per day).

Most Drugs Are Safe If:

They are commonly prescribed for infants

The amount the baby would get through the milk is much less than he would get if given directly.

They are considered safe in pregnancy

This is not always true, since during the pregnancy, the mother’s body is helping the baby’s get rid of drug. Thus it is theoretically possible that worrisome accumulation of the drug might occur during breastfeeding when it wouldn’t during pregnancy (though this is probably rare). However, if the concern is for the baby’s getting exposed to a drug, say an antidepressant, then the baby is getting exposed to much more drug at a much more sensitive time during pregnancy than during breastfeeding. Recent studies about withdrawal symptoms in newborn babies exposed to SSRI type antidepressants (Paxil, for example) during the pregnancy somehow managed to implicate breastfeeding as if this type of problem requires a mother not to breastfeed. (Good example of how breastfeeding is blamed for everything.) In fact, you cannot prevent these withdrawal symptoms in the baby by breastfeeding, because the baby gets so little in the milk.

They are not absorbed from the stomach or intestines

These include many, but not all, drugs given by injection. Examples are gentamicin (and other drugs in this family of antibiotics), heparin, interferon, local anaesthetics, omeprazole. Omeprazole (Losec, Prilosec) is interesting because it is destroyed very quickly in the stomach. During the manufacture of the drug, a protective layer is added to the drug to prevent its destruction and the drug is thus absorbed into the mother’s body. Thus, the drug is covered by a protective layer that prevents its destruction in the stomach. However, when the baby gets the drug (in tiny amounts incidentally) there is no protective layer on the drug, so it is immediately destroyed in the baby’s stomach.

They are not excreted into the milk

Some drugs are just too big to get into the milk. Examples are heparin, interferon, insulin, infliximab (Remicade), etanercept (Enbrel).

The Following Are A Few Commonly Used Drugs Considered Safe During Breastfeeding:

Acetaminophen (Tylenol, Tempra), alcohol (in reasonable amounts), aspirin (in usual doses, for short periods). Most antiepileptic medications, most antihypertensive medications, tetracycline, codeine, nonsteroidal antiinflammatory medications (such as ibuprofen), prednisone, thyroxin,propylthiourocil (PTU), warfarin, tricyclic antidepressants, sertraline (Zoloft), paroxetine (Paxil), other antidepressants, metronidazole (Flagyl), omperazole (Losec), Nix, Kwellada.

Note: Though generally safe, fluoxetine (Prozac) has a very long half life (stays in the body for a long time). Thus, a baby born to a mother on this drug during the pregnancy, will have large amounts in his body, and even the small amount added during breastfeeding may result in significant accumulation and side effects. These are rare, but have happened. There are two options that you might consider:

• Stop the fluoxetine (Prozac) for the last 4 to 8 weeks of your pregnancy. In this way, you will eliminate the drug from your body and so will the baby. Once the baby is born, he will be free of drug and the small amounts in the milk will not usually cause problems and you can restart the fluoxetine (Prozac).
• If it is not possible to stop fluoxetine (Prozac) during your pregnancy, consider changing to another drug that does not get into the milk in significant amounts once the baby is born. Two good choices are sertraline (Zoloft) and paroxetine (Paxil).

Medications applied to the skin, inhaled (for example, drugs for asthma) or applied to the eyes or nose, are almost always safe for breastfeeding.

Drugs for local or regional anaesthesia are not absorbed from the baby’s stomach and are safe. Drugs for general anaesthesia will get into the milk in only tiny amounts (like all drugs) and are extremely unlikely to cause any effects on your baby. They usually have very short half lives and are eliminated extremely rapidly from your body. You can breastfeed as soon as you are awake and up to it.

Immunizations given to the mother do not require her to stop breastfeeding. On the contrary, the immunization will help the baby develop immunity to that immunization, if anything gets into the milk. In fact, most of the time nothing does get into the milk, except, possibly some of the live virus immunizations, such as German Measles. And that’s good, not bad.

X-rays and scans. Ordinary X-rays do not require a mother to interrupt breastfeeding even when used with contrast material (example, intravenous pyelogram). The reason is that the material does not get into the milk, and even if it did it would not be absorbed by the baby. The same is true for CT scans and MRI scans. You do not have to stop for even a second.

What About Radioactive Scans?

We do not want babies to get radioactivity, but we rarely hesitate to do radioactive scans on them. When a mother gets a lung scan, or lymphangiogram with radioactive material, or a bone scan, it is usually done with technetium (though other materials are possible). Technetium has a half life (the length of time it takes for ½ of all the drug to leave the body) of 6 hours, which means that after 5 half lives it will be gone from the mother’s body. Thus, 30 hours after injection all of it will be gone (well 98% will be gone) and the mother can breastfeed her baby without concern about his getting radiation. But does all the radioactivity need be gone? After 12 hours, 75% of the technetium is gone, and the concentration in the milk very low. I think that waiting 2 half lives is enough, for a material such as technetium. But: Not all technetium scans require stopping breastfeeding at all (HIDA scan, for example). It depends on which molecule the technetium is attached to. In the first few days, there is very little milk (though there is enough). In this situation it would be unnecessary for the mother to stop breastfeeding after a lung scan, for example. However, one of the most common reasons to do a lung scan is to diagnose a clot in the lung. This can now be done better and faster with CT scan, which does not require interrupting breastfeeding for even 1 second.

If you decide that interruption of breastfeeding is the best course to follow, then express milk for several days in advance (if you have advance warning about the test) and this can be fed via cup for a few days. Then while not breastfeeding, express your milk but don’t throw away the milk. The radioactive tracer that is present in the milk decays and the radiation is gone in 5 half-lives. So, even for I¹³¹ used in thyroid scans (see below), the radioactivity of the iodine will be gone in 5 half-lives, so the milk can be used in 6 to 8 weeks (the half-life of I¹³¹ is about 8 days). Only occasionally is a radioactive scan so urgent that it cannot be delayed for a few days.

Thyroid scans are different. Radioactive iodine (I¹³¹) is concentrated in milk and will be ingested by the baby and it will go to his thyroid where it will stay for a long time. This is definitely of concern. So, the mother will have to stop breastfeeding? No, because often the test does not need to be done at all. Differentiating postpartum thyroiditis from Graves’ Disease (the most common reason for doing the scan in breastfeeding mothers) does not require a thyroid scan. Get more information from your doctor. If a scan needs to be done, it is possible to do a thyroid scan I¹²³ which requires stopping for only 12 to 24 hours, depending on the dose given or technetium (see above). Don’t forget to express milk in advance so the baby can get it instead of formula.

Breastfeeding and Medication, © 2009
Written and revised (under other names) by Jack Newman, MD, FRCPC, © 1995-2005 
Revised Jack Newman MD, FRCPC, IBCLC and Edith Kernerman, IBCLC, © 2008, 2009

WHO official explains stand on breastfeeding and HIV at international Lactation Consultants meeting

by Lenore Goldfarb

At the International Lactation Consultants Association Conference in Sydney, Australia this summer (2003), Lenore attended a lecture by James Akre of the World Health Organization (WHO), which included the WHO’s position on breastfeeding by HIV-positive mothers. Mr. Akre pointed out that this issue is not limited to third world countries but is in fact a global crisis with millions of children whose parents die of AIDS, leaving them behind. Some of these children are themselves infected. Many of these children reside in the West.

The case he presented concerned a father who contracted HIV though contaminated products to treat his haemophilia. He passed the virus on to his pregnant wife, who in turn passed the virus on to her unborn child. The entire family was wiped out except for their 12-year-old daughter, who became an AIDS orphan.

There is evidence that HIV can pass into breastmilk and infect the breastfeeding baby. But that is not the sole route of transmission. HIV can pass to the unborn foetus during pregnancy, or to the baby during birth as well. Health authorities in the United States recommend that an HIV-positive mother not breastfeed provided that there is an ample supply of artificial infant milk. If it is in powdered form, there must also be a safe, clean, ample supply of fresh water. This is sadly often not the case in developing countries and so the WHO recommendation is for exclusive breastfeeding for 6 months and then rapid weaning.

The rationale for this recommendation is that infants of HIV-positive mothers are far more likely to die from contaminated artificial infant milk than from transmission of HIV from their mothers. Previously it was thought that there is a 3% probability of transmission of HIV to the infant but James Akre quoted a 15% probability. The probability rises sharply after 6 months of exclusive breastfeeding or for those infants who are fed a combination of their mother’s milk and artificial infant milk and for that reason, the WHO recommends rapid weaning at 6 months. In spite of the 15% probability of transmission, WHO recommends the above because the benefits of breastfeeding far exceed the risk of illness and death by contaminated artificial infant milk.

It stands to reason that adoptive mothers are open to the risk of infection by babies of HIV-positive mothers if the infant is infected and breastfeeding is managed poorly. A poor latch can damage the mother’s nipples, with the broken tissue offering a site for transmission of the virus and subsequent infection. Proper assistance and good breastfeeding management can drastically reduce this risk. If the mother can bring in her milk supply, she can reduce her baby’s need for supplementation and further reduce the risks associated with the use of artificial infant milk.

La Leche League International released the following statement on July 4, 2001:

“La Leche League International acknowledges the worldwide challenge of making informed infant feeding decisions when HIV transmission is a consideration. Parents and health care providers are urged to weigh the well-known, documented health and emotional benefits of human milk and breastfeeding for both mother and child against the known, documented health hazards of breast milk substitutes, the rates of childhood illness and death from infectious diseases in the mother’s area of the world, and the incomplete understanding of the risk of HIV transmission through human milk. La Leche League International challenges the scientific community to undertake the research necessary to fully define the role of breastfeeding and human milk in HIV transmission and infant protection.

“In general, for women who know they are HIV-positive and where infant mortality is high, exclusive breastfeeding may result in fewer infant deaths than feeding breast milk substitutes and remains the preferred feeding approach. While breastfeeding where infant mortality is low may also carry a risk of HIV transmission for infants whose mothers test HIV positive, there is no clear, published evidence that feeding breast milk substitutes results in lower infant morbidity and mortality in any infants.

“The social costs of not breastfeeding also must be considered. When a woman gives breast milk substitutes in a culture where breastfeeding is traditional, her community may suspect that she is HIV-positive, potentially putting her at risk for physical abuse, ostracism, and abandonment. In most parts of the world women do not know their HIV status, therefore ongoing support of exclusive breastfeeding is most appropriate and much needed.

“While current scientific thinking accepts a risk of vertical transmission with breastfeeding in general, research studies that fully define the role of breastfeeding patterns (particularly exclusive breastfeeding and optimal breastfeeding management) and related maternal and child health on HIV transmission have not yet been done.

“LLLI is not making a recommendation about breastfeeding for HIV-positive mothers at this time due to the inconclusive nature of the research and its various interpretations.”

Vasospasm and Raynaud’s Phenomenon

These conditions are due to a spasm of blood vessels preventing blood from getting to a particular area of the body, typically the end of an extremity, though not necessarily. They often occur in response to a drop in temperature. Raynaud’s phenomenon will occur in the fingers, for example, when someone goes outside from a warm house on a cool day. The fingers will turn white and the lack of blood getting to the tips of the fingers will cause pain. Raynaud’s phenomenon occurs more commonly in women than men, and can be often associated with “auto-immune” illnesses such as rheumatoid arthritis.

Here, we will refer to both conditions as vasospasm. Vasospasm can also occur in nipples. In fact, it is much more common than generally believed. It can occur along with any cause of sore nipples, and is, in fact, probably a result of damage, but it may also, on occasion, occur without any other kind of nipple pain at all.

Typically, vasospasm occurs after the feeding is over, once the baby is already off the breast. Presumably, the outside air is cooler than the inside of the baby’s mouth. When the baby comes off the breast, the nipple is its usual colour, but soon, within minutes or even seconds, the nipple will start to turn white. This is likely also due to drying of the nipple. Mothers generally describe a burning pain when the nipple turns white. After turning white for a while, the nipple may actually turn back to its normal colour (as blood starts to flow back to the nipple), and the mother will notice a throbbing pain. See the video clip of a mother’s nipple going from white to pink. The nipple may go back and forth between colours (and types of pain) for several minutes or even an hour or two. Sometimes, the mother does not even notice her nipple turning white and instead sees it change form pink to red to purple and back to pink again. That the nipple changes colour is not the concern; that the mother is in pain is a concern. Interestingly some mothers do not have pain with the vasospasm.

The treatment for vasospasm is to fix the original cause of the pain (poor latch, Candida). See the information sheets Latching On, Candida protocol - Toronto and Sore nipples as well as the video clips. Almost always, as the nipple soreness from another cause is getting better, so will the pain from the vasospasm, but more slowly. Fixing the original cause of the pain(improving the latch, treating Candida etc) should be the focus of treatment. However, some mothers no longer have pain during the feeding, or never had it at all. Indeed, some start having vasospasm during the pregnancy. If the pain is mild, there may be no reason to treat, and reassurance is all that is necessary. However, it is worth treating when the pain is distressing to the mother, and especially if the pain during the feeding does not improve, as severe restriction of blood supply to the nipple may delay healing.

Treatments for Raynaud’s phenomenon (blanching of the nipple)

1. Identify and Fix the original cause of the pain: i.e. Poor Latching and/or Candida.
2. Stop Air Drying of the nipples. When baby comes off the breast, immediately cover the nipple with your warm hand while you get your bra done up. After talking a shower, avoid going out of the shower enclosure until the breasts are completely covered and kept warmed so the cold air cannot reach the nipples.
3. The All Purpose Nipple Ointment may also help for the soreness during the feeding, especially when ibuprofen powder has been mixed in. See the information sheets Candida protocol - Toronto and All purpose nipple ointment.
4. Olive Oil Warming olive oil in mother’s fingers and then gently massaging the oil into the nipples during the burning may be very soothing. We have heard from many mothers that this gave them instant relief and seemed to decrease the occurrence of the vasospasm overall. It’s important that the oil be really massaged into the nipples and not just dabbed on
5. Vitamin B6 Multi Complex. There have not yet been studies done to show that vitamin B6 works, but enough anecdotal evidence has come forward to support that it does work at least some of the time. It is safe and will do no harm. It is best that B6 not be taken on its own but instead as part of a B complex of vitamins that includes niacin. Depending on the overall dose of the B complex, the amount of B6 itself should be approximately 100 mg 2x/day for at least a couple of weeks. So, for example, if the overall capsule is 125 mg of B complex and there is only 50 mg of B6 in that capsule, then mother would need to take 2 capsules at a time to equal one dose and that dose would need to be taken 2x/day. The mother continues it until she is pain free for a few weeks. It can be restarted if necessary. If you have been pain free for a week or two, try going off the vitamin B6. If vitamin B6 does not work within a week, it probably won’t.
6. Warm dry compresses can be very effective at stopping the vasospasm as it is occurring and for treating the pain. Lying down after a feeding and applying a heating pad to the breasts for a few minutes or more may help considerably. Certainly, it will allow mother to rest and this may help to deal with the pain, as well.
7. Magnesium supplements with added Calcium taken as 2 teaspoons (300mg Magnesium/200 mg Calcium (gluconate), or taken separately: 2x daily or 30mg Magnesium 2x daily & 200mg of Calcium.)

8. After working on the latch, possibly as effective as all of the above is the massaging of the chest muscles which are below the collar bone and above the breasts after the feedings or at onset of nipple or breast pain. The massage should be very vigorous and firm and is done on the chest, not necessarily the breasts. The mother could also massage under the pectoral muscles, in her armpits, but this massage should be done gently.

   When this is not enough:

9. Nifedipine. This is a drug used for hypertension. One 30 mg tablet of the slow release formulation once a day often takes away the pain of vasospasm. After two weeks, stop the medication. If pain returns (about 10% of mothers), start it again. After two weeks, stop the medication. If pain returns (a very small number of mothers), start it again. No mothers I am aware of took more than three, two week courses. Side effects are uncommon, but headache may occur. It is a prescription drug. The dose can be increased if 1 tablet is insufficient. The nifedipine treatment may be used in conjunction with all of the other treatments listed above.

Note: We no longer recommend nitroglycerin paste, as severe headache associated with its use is fairly common. It also does not work more than about 50% of the time.

Vasospasm, © 2009 
Written by Edith Kernerman, IBCLC, © 2008
Revised by Jack Newman MD, FRCPC and Edith Kernerman, IBCLC, © 2008, 2009