Lactation- Higginss

What specific antimicrobials are safe for breastfeeding?

Which are controversial?

• safe:

  • penicillins

  • cephalosporins

  • macrolides

  • aminoglycosides

• controversial

  • fluoroquinolones

  • metronidazole

  • nitrofurantoin

What beta-blockers have the lowest transfer into milk?

• propranolol

• metoprolol

• labetalol

What CCBs have the lowest transfer into milk?

• non-DHPs—> verapamil and diltiazem

• nifedipine

Should ACE inhibitors be used during pregnancy?

idk how important

• captopril and enalapril have been reviewed and are compatible with first weeks of life

• transferred at low levels but neonates are extremely sensitive

Can cough and cold products like histamine and nasal decongestants be used during breastfeeding?

What is the preferred antihistamine?

• antihistamines—> loratadine preferred

  • 1st gen have anticholinergic properties

  • benedryl crosses into breast milk

• nasal decongestants—> pseudoephedrine is fine

Can APAP be used when breastfeeding?

enters breast milk—> but considered safe

Can NSAIDs be used when breastfeeding?

• Ibuprofen and ketorolac considered safe

• long acting NSAIDs only for short term therapy

• aspirin—> low dose okay/ not high dose

What does the FDA say about opioid use when breastfeeding?

• FDA discourages use

• brief periods of use may be okay if necessary

• avoid meperidine, oxycodone, hydrocodone, and codeine

Can anticoagulants, specifically warfarin and heparin be used when breastfeeding?

yep!

Most vaccines may be administered to mother’s while lactating.

What 2 are C/I in non-emergency situations?

When should caution be used with the HPV vaccine?

• C/I in non-emergency—> smallpox and yellow fever

• HPV—> caution in infants who are vulnerable to respiratory illness

Caffeine should be limited to ___-___ mg/day while breastfeeding.

200-300

Can you drink alcohol while breastfeeding?

• ingest minimally

• don’t nurse during ingestion and for 2 hours after (a single serving)

  • wait an additional 2 hrs for each serving

Can you smoke tobacco while breastfeeding?

What about nicotine cessation therapy?

• tobacco use not a C/I—> but discouraged

• nicotine replacement therapy is okay as long as dose is < than # of cigarettes normally smoked

What are the phases of breastmilk?

• phase 1—> colostrum

  • “liquid gold”, milk just after birth, rich in nutrients/abs

• phase 2—> transitional milk

  • 2-5 days- 2 weeks after birth

  • changes

• phase 3—> mature milk

  • 10-15 days after birth

Who should be supplemented with Vitamin D and iron?

• all infants should be supplemented with Vit D

• preterm infant that’s breastfed—> receive iron starting at 1m to 12m

• at term infants—> start at 4m to they can eat foods

Why do we not use prenatal vitamins during lactation?

• bc they are formulated for pregnancy not lactation

• supplement with just folic acid instead

What are the breastfeeding recommendations from the AAP and WHO?

• exclusive breastfeeding for ~6 months

• continue with appropriate complementary foods for up to 2 years of age or older

“BREAST IS BEST”

What are the benefits for the mother AND the infant from breastfeeding?

• pros for the infant:

  • reduced risk of: asthma, obesity, T1DM, severe lower respiratory disease, acute otitis media, SIDS, GI infections, necrotizing enterocolitis

• pros for the mother:

  • lower risk of HTN, T2DM, ovarian and breast cancer

What is mastitis?

• Is it infectious or noninfectious?

• most common cause?

• s/sx?

• mastitis—> inflammation of the breast

• infectious or noninfectious

• most common cause—> milk stasis

• s/sx: breast tenderness, redness, warmth, flulike s, chills, fever

1st line tx for mastitis? alternatives? non-pharm?

• 1st line: 10-14 day course of penicillinase-resistant penicillins (oxacillin, dicloxacillin)

• alt: 1st gen cephalosporins

• non-pharm:

  • heat breast prior to feeding

  • massage breast

  • cold compress after feeding

Agents that stimulate lactation are called ____________.

galactagogues

What pharm agents are galactagogues?

• domperidone

• metoclopramide

What does the ABM and AAP recommend for galacagogues?

DUE TO LOW EVIDENCE—> CANNOT RECOMMEND ANY AT THIS TIME

What herbs are galactagogues? (note: little evidence for effectiveness)

• fenugreek

• milk thistle

• others: goat’s rue, oats, dandelion, millet, seaweed, basil, marshmallows

What are the C/I to breastfeeding?

• inborn errors of metabolism—> galactosemia

• maternal illicit substance use

• infections

  • HIV, ebola, tuberculosis, varicella

  • temp—> mpox, herpetic lesions, brucellosis

What meds are C/I in lactation?

• amiodarone

• bromocriptine

• chemo drugs

• ergotamine

• isotretinoin

• lithium

What are maternal, drug, and infant parameters to consider when using drugs in lactating mothers?

What are some other factors that influence drug concentration in human milk?

• maternal

  • Drug, dose, duration of therapy

  • Route and frequency of administration

  • Metabolism

  • Renal clearance

  • Blood flow to the breast

  • Milk pH

  • Milk Composition

• drug

  • oral bioavailability

  • MW

  • pka, lipid solubility, protein binding

• infant

  • age

  • feeding pattern

  • amount of milk consumed

  • ADME

• other factors:

  • admin timing

  • elimination t ½

  • diffusion

  • “pumping and dumping” not really useful

True or false: if a drug is contraindicated in pregnancy it’s contraindicated in lactation.

False

What parameters help assess the safety of medications during lactation by quantifying how much drug transfers into breast milk and how much the infant ingests?

• milk/plasma ratio

• infant dose

• relative infant dose

What happens is the Milk/Plasma ratio or M/P is >1?

infant is at increased risk

infant dose = ________________ x __________________

relative infant dose (RID)= ______________/_____________x 100

infant dose= drug concentration in milk x volume of milk ingested

RID= (infant dose mg/kg/day)/(maternal dose mg/kg/day) x 100

<___% of maternal dose often considered to be safe (dose not account for infant pharmacodynamics)

10

Where can mothers find info on whether or not drugs are safe during lactation?

• package inserts

• brigg’s drugs in pregnancy and lactation

• LactMed

• Dr. Thomas Hale’s medications and mother’s milk

• mother to baby medication fact sheets

• AAP clinical report

HIGGINS REVIEW:

1. Properties allowing transfer of drug into breastmilk

2. Phases of breastmilk

3. Drug references for providers and patients to look up safety of

   medications during lactation

4. Benefits of breastfeeding to mother and baby

5. Specific medication classes and breastfeeding

1. properties:

   • more likely to pass if: Low MW, non-ionized, not protein bound, highly lipid soluble, weak bases, high bioavailability

   • maternal parameters to consider:

     • drug/dose, duration of therapy

     • route/frequency of admin

     • metabolism

     • renal clearance

     • blood flow to breat

     • milk pH and composition

   • drug parameters to consider

     • oral bioavailability

     • MW, pKa, lipid solubility, protein binding

   • infant parameters to consider:

     • age

     • feeding pattern

     • amount of milk consumed

     • ADME

   • others:

     • timing of admin

     • t ½

     • diffusion

2. phases:

   • phase 1: colostrum

     • thick first milk just after birth—> “liquid gold”

     • very rich in nutrients and abs

   • phase 2: transitional milk

     • 2-5 days after birth up to 2 weeks

     • bluish-white color

   • phase 3: mature milk

     • 10-15 days after birth

3. drug references:

   • package inserts

   • brigg’s drugs in pregnancy and lactation

   • LactMed

   • Dr. Thomas Hale’s medications and mother’s milk

   • mother to baby medication fact sheets

   • AAP clinical report

4. benefits of breastfeeding:

   • infant: reduced risk of—> asthma, obesity, T1DM, respiratory disease, AOM, SIDs, GI infections, necrotizing enterocolitis

   • mother: lower risk of HTN, T2DM, ovarian cancer, breast cancer

5. specific medications:

   • C/I: amiodarone, bromocriptine, chemo drugs, ergotamine, isotretinoin, lithium

   • antimicrobials

     • good: penicillins, cephalosporins, macrolides, aminoglycosides

     • controversial: fluroquinolones, metronidazole, nitrofurantoin

   • b-blockers: propranolol, metoprolol, and labetalol lowest transfer

   • antihistamines—> loratadine best

   • APAP—> safe

   • NSAIDs—> can be used, specific recs

   • opiates—> FDA discourages use but can be used in brief periods

   • warfarin and heparin—> safe

   • vaccines—> 2 C/I in nonemergencies, careful with HPV in respiratory illnesses