수유 중 약물복용• 분만 후 1주일 동앆 90%가 medication – 평균 3.9drug 복용 – 22%가 항생젗 복용• 수유 중에 약을 먹으면 아기에게 악영향을 줄 것으로 생각• 약을 처방했을 때 한 연구에 의하면 22%가 약을 먹지 않거나 모유 수유를 중단한다.• 수유 중 약물복용에 대한 적절한 충고가 필요하다.
Medication during breastfeeding• Nearly all drugs pass into human milk• Almost all medication appears in small amounts, usually less than 1% of the maternal dose• Very few drugs are contraindicated for nursing mothers
Route of drugs from mother to baby via breastmilk Drug Oral bioavailability varies High (>90%) Low (<50%) Acetaminopen Acyclovir Lorazepam Azithromycin Maternal gut and liver Metronidazole Budesonide Minoxidil Sulfasalazine Maternal plasma Dilution of all drugs leads to low concentrations in mother’s plasma Only drugs are not protein-bound can pass into milk Drug protein binding High Low Bepridil >99% Bisoprolol 30% Diazepam 99% Cyclophosphamide 13% Diclofenac >99% Ranitidine 15% Propranolol 90% Primidone <20%Oral bioavailiability varies Infant gut Usually very low levels (often undetectable) Infant plasma
Methods of drug transfer into milk• Passive diffusion• Active transport against a concentration gradient• Transcellular diffusion
• Diffusion – Plasma levels in the mother – Lipid solubility of the drug and fat content of milk – Milk ph – Molecular size of the drug – Protein binding of the drug in mother’s plasma – Maternal half-life of the drug – Molecular weight of drug – Bioavailability of the medication to the infant
LACTATION RISK CATEGORY BY THOMAS W HALE• L1 safest• L2 safer• L3 moderately safe• L4 possibly hazardous• L5 contraindicated
DRUG CLASSIFICATION BY AAP• Cytotoxic drugs• Drugs of abuse for which adverse effects on the infant• Radioactive compounds that require temporary cessation of breastfeeding• Drugs for which the effect on nursing infants in unknown but may be concern• Drugs that have been associated with significant effects on some nursing infants and should be given to nursing mothers with caution• Maternal medication usually compatible with breastfeeding
Drug transfer into the breast milk• Maternal factor – Dose and duration of therapy – Route of administration – Drug pharmacokinetics• Infant factor – Infant’s ability to absorb, metabolize, and excrete the drug – Gestational age of infant and its postnatal age
Way to minimize infant drug exposure• Avoid feeding the infant at the time of peak concentration of the drug in milk.• Withhold breastfeeding temporarily if the drug is only used for a short duration.• Choose drugs for the mother that have known and established information about their pharmacokinetics and toxicity and have low concentrations in breast milk and low relative infant dose• Choose drugs that can be locally rather than systemically administered• In case of long-acting drugs, time the drug administration to a once-a-day dose just before the infant’s longest sleep period to lessen exposure.
Evaluation of the infant• Infant age – Premature and newborn infants are at somewhat greater risk• Infant stability – Unstable infants with poor GI stability may increase the risk of using medications• Pediatric approved drugs – Generally are less hazardous if long-term history of safety is recognized• Dose – In a premature infant various doses may be more risky than in a 1 year old healthy infant• Drugs that alter milk production – May be much more risky during neonatal period than much later
상담 시 주지 사항 및 상담내용• 약을 꼭 복용해야 하는지 평가한다.• 젖을 빨리고 난 다음 약을 복용한다.• 약물을 단기갂 사용 할 경우에는 수유를 잠시 멈춘다.• 정확한 정보가 있는 약으로 아이에게 영향이 적은 약을 선택하게 한다.• 전싞적으로 작용하는 약보다는 국소적으로 작용하는 약을 선택하게 한다.
Reasons for using the telephone line in breastfeeding women Hemorrhoid CV disease GI disease Contraception Thyroid disease 7.4% Hepatitis B Dermatologic disease 12.5%11% Respiratory disease Inflamation Others Pain Psychotic disease Dental disease Nutrition Breast problem 9.6%
Drugs prescribed for breastfeeding women Antihistamine Regional agents GI drugs Miscellaneous CV agents CNS agents & Analges Nutritional agents Natural & Herbal pro Endocrine agents Systemic antibiotics Respiratory agents