Prescribing in breastfeeding

when is breastfeeding recommended?

first 6 months of life and continue for at least 1 year of life

how is breastfeeding important to the baby?

boosts babies immune function

reduce incidence diarrhoea, iron related anaemias, respiratory and UTI infections

benefits of breastfeeding to the mother

• lowers BP and reduces blood post-partum

• dec risk of hip fracture, osteoporosis and RhA

• protection against breast cancer

• possible reduced risk of ovarian cancer

• reduced risk of postmenopausal cardiovascular disease

• improves mood

• bonding with baby

• convienient, flexibile and cost effective

how is cocaine dangerous in breastfeeding

loads of it enters the milk = high risk

factors to consider for medication safety in breatfeeding?

• maternal plasma concentrations - less likely to transfer into milk if high ?

• bioavailability

• drug properties

• metabolism and elimination

Low risk pain relief

paracetamol

ibuprofen

diclofenac

tramadol

dihydrocodeine

morphine at LOW DOSE

why should codeine not be given during breatfeeding?

metabolised to Morphine via CYP2D6

• some people have xs CYP2D6 and are ultra-rapid metabolisers

risk of gabapentin/pregablin during breastfeeding

(painkillers)

→ small molecule with low protein binding = PASSES into breastmilk

which antibiotics to use WITH CAUTION

nitrofurantoin - not in premature infants, younger than 2 weeks of age

metronidazole - short-term and monitor GI effects

macrolides - erythromycin - avoid 1st month

clarithromycin- low risk but monitor GI side effects

which SSRIs are preferred in BF and why

paroxetine/ sertraline because of their short half life

what are the tricyclic choice (TCA’s) during breastfeeding?

Imipramine and nortriptyline

• less sedating and reduced risk of infant sedation

(long half life- accumulation and inc side effects)

why is it okay to give most TCAs?

undergo first pass metabolism so the actual amount left for an infant to absorb is alot less.

which anxiolytics are best to use

short-acting BZs like:

• lorazepam, oxazepam at lowest effective dose

what to give mother with sleeping disorders?

Z-drugs

• Zopliclone and zolpidem

Withdrawal effects may occur in infants if the mother suddenly stops breastfeeding!

what is a practical reason you may not give Z-drugs?

if mother is sleeping, who will take care of baby?

talk thru with the patient and see best options

which type of antipsychotics are preffered?

oral and non-depot

less sedating properties

short half life

is haloperidol safe to give (antpsychotic)

not really, excreted in variable amounts of milk so could be clinically significant

max dose olanzapine thats ok to give

doses up to 20mg daily - produce low levels in breastmilk

is lithium safe to give

USE WITH CAUTION- monitor baby regularly for signs of lithium toxicity

• monitor poor feeding, weight gain, changes in behaviour, diarrhoea..

Which class of anticoagulants are face to use in breastfeeding? and why?

LMWH or Unfractionated Heparin is both safe to use

• large enough so little gets into breast milk

• inactivated in GI

you cant give warfarin in pregnancy, but can you give it in breastfeeding?

yes!

it is the oral anticoagulant choice in breastfeeding -

very high protein bound so less free drug to pass into milk

which DOACs are not recommended in breastfeeding?

Apixaban and Edoxaban

• levels in milk are high

what are the recommended BBS for during pregnancy (first choice)

labetalol, metoprolol, propanolol

• very small amounts get into milk

2nd BB choices

Atenolol - excreted in small to moderate amounts

Bisoprolol- use with caution! high BA and low protein binding so would be excreted into breastmilk

preferred choice of CCbBs

nifedipine and verapamil

what is the ACE inhibitor choice in breastfeeding?

Enalapril - used therapeutically in infans and has favourable PK

• active metabolite is poorly absorbed

low risk anti-epileptics

lamotrigine

carbamazepine

phenytoin

topiramate

valproate