Prescribing in breast feeding

benefits of breastfeeding in babies

increased cognitive function

decreased risk of iron anemia, breastmilk

provides IgA while baby develops

recommended for 6 months

good for pre-term babies

Benefits of breastfeeding to mother

lowers bp

Decreased risk of osteoprosis

reduced risk of ovarian and breast cancer

improved moood, bonding with baby

reduced costs on NHS

What happens to medicine while breastfeeding

• Complete a risk assessment before medication is started before baby is born

• Don’t just stop medication as this can still present risks in needing to treat maternal condition

• need to consider which medication, dose, route, frequency, duration of treatment, medical Hx if exclusively breastfeeding

• gestation, renal/liver function, which medicines does the baby have

Where can we get information on prescribing in breastfeeding

• SPS

• e-lactancia

• LactMed

• BNFC

• Briggs drugs in pregnancy and lactation

Describe which drugs should be avoided

LMW and high fat solubility

binds to breast milk albumin

cytotoxic drugs

cocaine

• Maternal plasma conc

• BA

• drug properties

• acid base balance

• protein binding capacity

• fat solubility

• MW

  • half-life, 5 half lives before safe to use mother may pump a few times to flush out the medicine

Paracetamol

Small amounts in breast milk

Ibuprofen

tiny/zero transfer to breast milk

Diclofenac

tiny/zero transfer to breast milk

tramadol

clinically insignificant amounts in milk

Dihydrocodeine

little published data but extensive anaecdotal

Codeine

codeine → morphine

Metabolised in the liver

CYP2D6 enzymes excess = fast metabolizers

can lead to accumulation in babies and neonatal deaths

Morphine

strong opioid

use lowest effective dose

short term

use non-opidoids alongside to reduce need for morphine

infant monitoring

Gabapentin and pregabalin

• small molecule

• low protein binding

• small amounts of transfer

pregabalin:

• small molecule

• low protein binding

• can pass to breast milk

monitor

s/e = poor feeding, drowsiness, respiratory depression, GI disturbances

penicillins

uFlucloxacillin, Pen V and Amoxicillin are all ok to use – lots of evidence and experience to support use

uAll acidic in nature so negligible quantities pass into milk

uLots of these are also used for treatment in neonates

nitrofuratoin

uExcretion into breastmilk is clinically insignificant

Not to be used in premature infants, younger than 2 weeks of age, G6PD deficiency, jaundice – risk of neonatal haemolysis

metronidazole

uExcreted in moderate amounts (low molecular weight; low protein binding), fully orally bioavailable, short half-life, minimal risk accumulation. Ok to use short courses, monitor GI effects

uPremature or new-borns are unable to metabolize metronidazole well so use minimum effective dose or see alternative

gentamicin

uExcreted in insignificant amount

uPoorly absorbed from G.I.Tract

uUsed in Neonates

macrolides

uErythromycin

uExcreted in negligible amounts

u?Potential risk of hypertrophic pyloric stenosis – avoid in 1^st month life

clarithromycin

uExcreted in negligible amounts

uLow risk – monitor for G.I Side effects

SSRI’s

uParoxetine and Sertraline are SSRI’s of choice due to shorter half-lives and pass into milk in smaller amounts compared to others

fluoxetine

we don’t switch as babies can experience withdrawal symptoms

tricyclics

uImipramine and nortriptyline are TCAs of choice as less sedating and reduce risk of infant sedation

uMost can be used – limited evidence shows levels are low and because TCAs undergo first-pass metabolism the actual amount available for infant to absorb are substantially less.

uLong half-lives could result in accumulation and increased side-effects

Front: What are the preferred benzodiazepines for breastfeeding mothers?

Back: Short-acting benzodiazepines like lorazepam and oxazepam are preferred. Use the lowest effective dose.

Front: Why is diazepam not recommended for breastfeeding mothers?

Back: Diazepam is a longer-acting benzodiazepine that is excreted in milk in clinically significant amounts, increasing the risk of sedation and poor sucking in infants.

Front: What are the recommended sleep medications for breastfeeding mothers?

Back: 'Z' drugs like zopiclone and zolpidem are preferred as they have a short half-life and are excreted in small amounts in breast milk.

Front: What is a potential risk if a mother suddenly stops breastfeeding while taking benzodiazepines?

Back: Withdrawal effects may occur in the infant if the mother suddenly stops breastfeeding.

What is a potential risk if a mother suddenly stops breastfeeding while taking benzodiazepines?

Withdrawal effects may occur in the infant if the mother suddenly stops breastfeeding.

What are the preferred benzodiazepines for breastfeeding mothers?

Short-acting benzodiazepines like lorazepam and oxazepam are preferred. Use the lowest effective dose.

Why is diazepam not recommended for breastfeeding mothers?

Diazepam is a longer-acting benzodiazepine that is excreted in milk in clinically significant amounts, increasing the risk of sedation and poor sucking in infants.

What are the recommended sleep medications for breastfeeding mothers?

'Z' drugs like zopiclone and zolpidem are preferred as they have a short half-life and are excreted in small amounts in breast milk.

What type of antipsychotics are preferred for breastfeeding mothers?

Oral and non-depot antipsychotics with less sedating properties and a short half-life are preferred.

Why should haloperidol use be monitored in breastfeeding mothers?

Haloperidol is excreted in milk in variable amounts, which could be clinically significant.

What are the considerations for olanzapine use in breastfeeding mothers?

Doses up to 20 mg daily produce low levels in breast milk, but due to its long half-life, monitoring for accumulation effects like sedation and poor feeding is necessary.

Which antipsychotics are excreted in small or insignificant amounts in breast milk?

Risperidone is excreted in small amounts. Quetiapine is excreted in clinically insignificant amounts.

Is lithium safe in infants

uExcreted in milk in moderate amounts which could be clinically significant

uPlasma levels in infant can reach 10% to 60% of therapeutic levels in mother

uUse with caution – regular checks on infant for signs of lithium toxicity – monitor poor feeding, poor weight gain, changes in behaviour, diarrhoea, monitoring, tremor

uCan do infant lithium levels

is methylphendate safe

uExcreted in milk in clinically insignificant amounts or not at all

uNo short or long term problems observed in infants exposed via breastmilk

uMonitor weight gain and irritability

Are heparins safe

LMWH are safe

LMW so won’t get into breast milk

inactivated by GI so unlikely to get into infants system

Is warfarin safe

No safe in pregnancy

Safe in breastfeeding: very highly bound so less free drug to pass into milk

Are DOACs safe to use

uAll DOAC’s may pass into breast milk

uDabigatran is one of the largest DOAC molecule and has a large volume of distribution so would be expected to pass into breast milk in low amounts. It also has very low oral bioavailability, so infant unlikely to absorb clinically significant amounts

Are factor Xa anticoagulants safe in breastfeeding

uRivaroxaban

uFrom the pharmacokinetic data – large volume of distribution and high percentage of protein binding – very small passage in to milk

uApixaban and Edoxaban are not recommended

uApixaban levels in milk appear to be quite high

uNo published evidence available on Edoxaban

uMonitoring infant

uBruising and bleeding – in vomit, urine, stools

Which anti-hypertensives are safe in pregnancy

Labetalol, metoprolol, propanolol are beta blockers of choice

small amounts in milk, short half life, low risk

uAtenolol – excreted in small to moderate amounts

Bisoprolol: caution as long half life could have accumulation

Calcium channel blockers

uNifedipine and Verapamil are the preferred choice

Amlodpoine, felodipine, long half life acucumuation in breast milk

Which ACEi is used in breast feeding

Enalapril: active metabolite is poorly absorbed orally and negligible amounts in milk

Which antiepileptics are safe in breastfeeding

levetiracetam: variable amounts in breast milk but low levels in infants, monitor for drowsiness

lamotrigine: lots of published evidence, significant amounts in milk, long-half life increases risk of accumulation

monitor rash, apnoea, drowsiness, poor feeding

Other safe anti-epileptics

uCarbamazepine 

uVery low risk and compatible with breastfeeding - Excreted in small amounts

uPhenytoin

uVery low risk, excreted in clinically non-significant amounts

uTopiramate

uVery low risk, moderate amounts excreted into breast milk, but no observed effects in infant

uValproate

uVery low risk, excreted in clinically insignificant amounts

uRisk of significant birth defects and developmental disorders, so not recommended to be used in women of child-bearing age