Medications and Lactation: Principles for Safe Practice for the Clinician

1. Medications and Lactation: Principles for Safe Practice for the Clinician Evelyn Fulmore, Pharm.D. McLeod Regional Medical Center Florence, SC

2. Disclosures  No financial relationships or duality of interest to disclose  I will be discussing use of agents to improve milk supply (galactagogues)

3. Learning Objectives  Basic physiology of lactation and mechanisms of medication entry into mother’s breast milk  Factors to consider when selecting medications during lactation  Role of galactagogues in lactation induction  Tips in utilizing and interpreting available lactation drug information resources

4. Physiology of LactationPhysiology of Lactation  Suckling stimulatesSuckling stimulates nipplenipple →→ pituitary glandpituitary gland secretes oxytocinsecretes oxytocin →→ letlet down reflex results indown reflex results in milk ejecting cellsmilk ejecting cells contract forcing milkcontract forcing milk from milk cells into milkfrom milk cells into milk ducts.ducts.

5. Physiology of LactationPhysiology of Lactation  Milk pools in laciferousMilk pools in laciferous sinuses under thesinuses under the areola. Sucklingareola. Suckling stimulates milk to comestimulates milk to come from the nipple.from the nipple.

6. Composition of BreastmilkComposition of Breastmilk  ColostrumColostrum (Days #3-5)(Days #3-5) high protein, immunoglobulins, minerals, low inhigh protein, immunoglobulins, minerals, low in lactose and fatlactose and fat  Transitional milkTransitional milk (Days #6-10)(Days #6-10) high in fat, lactose; lower in protein and mineralshigh in fat, lactose; lower in protein and minerals  Mature milkMature milk (Day #14)(Day #14) 60-80% whey protein, 50% fat, 40% lactose, growth60-80% whey protein, 50% fat, 40% lactose, growth factor, low in Vitamin Dfactor, low in Vitamin D

7. Factors Affecting Amount of Drug Received by the Infant  Milk yield  Colostrum versus Mature milk  Concentration of drug in the milk  How well the breast was emptied during the previous feeding  Infants ability to absorb, detoxify, and excrete the drug

8. Transfer of Medications intoTransfer of Medications into Breast MilkBreast Milk  Concentration gradientConcentration gradient – Passive diffusion of non-ionized and free (non-Passive diffusion of non-ionized and free (non- protein bound) medsprotein bound) meds – Maternal serum drug concentrationMaternal serum drug concentration volume of distribution (Vd) and half-lifevolume of distribution (Vd) and half-life - Retrograde diffusion of drug from breast milk toRetrograde diffusion of drug from breast milk to plasmaplasma Spencer JP et.al. Medications in the Breast-Feeding Mother. AFP 2001;Spencer JP et.al. Medications in the Breast-Feeding Mother. AFP 2001; 64:11964:119

9. Transfer of Medications intoTransfer of Medications into Breast MilkBreast Milk 1.1. Lipid solubilityLipid solubility 2.2. Molecular weightMolecular weight 3.3. Maternal plasma levelsMaternal plasma levels 4.4. Maternal protein bindingMaternal protein binding 5.5. Oral bioavailability, half lifeOral bioavailability, half life 6.6. Ion trapping (pKa)Ion trapping (pKa)

10. Lipid SolubilityLipid Solubility  Drugs that are highly lipid soluble penetrateDrugs that are highly lipid soluble penetrate milk in higher concentrationsmilk in higher concentrations  Avoid extremely lipid soluble drugs.Avoid extremely lipid soluble drugs.  Examples: Diazepam, phenobarbitalExamples: Diazepam, phenobarbital

11. Molecular WeightMolecular Weight  The lower the molecular weight (<200 D), theThe lower the molecular weight (<200 D), the greater penetration into milkgreater penetration into milk  Molecular weights <300 D : (eg. Alcohol,Molecular weights <300 D : (eg. Alcohol, amphetamines, diet pills)amphetamines, diet pills)  Molecular weightsMolecular weights ≥ 600 D : (eg. Heparin,≥ 600 D : (eg. Heparin, Enoxaparin, Insulin, Remicade)Enoxaparin, Insulin, Remicade)  Larger the molecular weight/size (preferred)Larger the molecular weight/size (preferred)

12. Maternal Plasma levelMaternal Plasma level  The most important determinant of drugThe most important determinant of drug penetration into milkpenetration into milk  As maternal plasma levels rise, theAs maternal plasma levels rise, the concentration in milk risesconcentration in milk rises  Drug delivery systems that result in lowDrug delivery systems that result in low maternal plasma levels are preferred inmaternal plasma levels are preferred in breast feeding mother (eg. Inhaler med,breast feeding mother (eg. Inhaler med, topicals)topicals)

13. Maternal Protein BindingMaternal Protein Binding  Most important parameter in choosing aMost important parameter in choosing a safe drug for a nursing mothersafe drug for a nursing mother  Most drugs circulate in the maternalMost drugs circulate in the maternal plasma bound to albuminplasma bound to albumin  ““Free” or “Unbound” drug transfers intoFree” or “Unbound” drug transfers into milkmilk  Drugs that are highly protein boundDrugs that are highly protein bound remain in the maternal plasma and don’tremain in the maternal plasma and don’t penetrate tissues or breast milkpenetrate tissues or breast milk

14. Oral BioavailabilityOral Bioavailability  The amount of drug that is absorbed by theThe amount of drug that is absorbed by the infant’s GI tract and reaches the circulationinfant’s GI tract and reaches the circulation  Low oral bioavailability: aminoglycosides,Low oral bioavailability: aminoglycosides, heparin, insulin, omeprazoleheparin, insulin, omeprazole  Action of a drug in the GI tract may produceAction of a drug in the GI tract may produce SE: diarrhea, constipation, PMCSE: diarrhea, constipation, PMC

15. Ion Trapping (pKa)Ion Trapping (pKa)  Ion trapping – drug becomes trapped in milkIon trapping – drug becomes trapped in milk compartment (due to low pH milk)compartment (due to low pH milk)  pKa is the pH where a drug is equally ionic orpKa is the pH where a drug is equally ionic or nonionic (the more ionic, less transfer fromnonionic (the more ionic, less transfer from milk to plasma)milk to plasma)  Drugs with high pKa (>7.2), have higherDrugs with high pKa (>7.2), have higher Milk/Plasma ratio (eg.Phenobarbital,Milk/Plasma ratio (eg.Phenobarbital, iodinated drugs)iodinated drugs)  Choose drugs with a low pKaChoose drugs with a low pKa

16. Drugs That Decrease Milk SupplyDrugs That Decrease Milk Supply  NicotineNicotine  AlcoholAlcohol  Sedating Antihistamines (eg. Diphenhydramine)Sedating Antihistamines (eg. Diphenhydramine)  Estrogen containing oral contraceptivesEstrogen containing oral contraceptives  Progesterone contraceptives (if started earlyProgesterone contraceptives (if started early postpartum before milk supply established)postpartum before milk supply established)  Bromocriptine (Parlodel)Bromocriptine (Parlodel)

17. Drugs That Aid in Milk Production: Galactagogues  Herbals: Fenugreek  Metoclopramide (Reglan)  Domperidone (Motillium)  Synthetic Oxytocin nasal spray

18. Galactagogues  Used to increase breast milk supply  Need to determine the etiology of low milk supply  Ensure proper breastfeeding technique  Only use with adequate milk removal  Must evaluate for medical co-morbidities (e.g. hypothyroidism, retained placenta)

19. Herbal: Fenugreek  Trigonella foenum graecum  MOA: stimulate sweat production; Phytoestrogen and Diosgenin - increase milk flow  Tea (bitter taste), capsule or tablet  Sweat and urine (maple syrup smell)  Caution use in Asthma or diabetes  Contains coumarin (interact with NSAIDS)  No scientific data

20. Domperidone (Motillium)  Not approved for use in the US  MOA: increase prolactin → milk production  Maternal safety has not been established  FDA warning concerning reports of QT interval prolongation, cardiac arrest, sudden death (IV formulation)  Clinical trial showed increase breastmilk volume without affecting nutrient composition Campbell-Yeo M. Effect of Domperidone on Compositiono of Preterm Human Breast Milk. Pediatrics 2010; 125 (1):e107-e114

21. Metoclopramide (Reglan)  Most commonly used  MOA: increase prolactin  Caution: clearance of metoclopramide in the neonate is prolonged can result in side effects (methemoglobinemia)  Short term use recommended (1-3 weeks)  Common dosing: 1st day – 10 mg, 2nd day – 10 mg bid, thereafter 10 mg tid

22. Synthetic Oxytocin Nasal Spray  Hormone (synthetically derived)  MOA: causes release of milk from milk glands to the ducts (helps empty the breast)  Prepared by compounding Rx (10 unit/ml)  Dose: 1-2 sprays each nostril before breast feeding or pumping

23. Synthetic Oxytocin Nasal Spray: Mean Daily Milk Production Fewtrell MS. Arch Dis Child Fetal Neonatal Ed. 2006 May; 91(3): F169–F174.

24. Safety Data and Breast FeedingSafety Data and Breast Feeding  Breast feeding lacks standardized riskBreast feeding lacks standardized risk categoriescategories  Most of the data on meds and breast feedingMost of the data on meds and breast feeding are from scientific literatureare from scientific literature  Given the lack of standardization, otherGiven the lack of standardization, other recommendations for using meds whilerecommendations for using meds while breast feeding have been used by healthbreast feeding have been used by health care providerscare providers Master KP et.al. Breast Feeding and OTC medications. US Pharm 2007; 32 (7): 8-12Master KP et.al. Breast Feeding and OTC medications. US Pharm 2007; 32 (7): 8-12

25. Lactation ResourcesLactation Resources  BooksBooks – Gerald G. Briggs. “Gerald G. Briggs. “DrugsDrugs in Pregnancy andin Pregnancy and Lactation: A referenceLactation: A reference Guide to Fetal andGuide to Fetal and Neonatal Risk”, 9Neonatal Risk”, 9thth edition; 2012edition; 2012

26. Briggs GG et. al. Drugs in Pregnancy andBriggs GG et. al. Drugs in Pregnancy and Lactation, 2008; 8th editionLactation, 2008; 8th edition Definitions of Breast Feeding Recommendations  Compatible  Hold Breast Feeding  No (limited) Human Data – Probably Compatible  No (limited) Human Data – Potential Toxicity  No (limited) Human Data – Potential Toxicity (Mother)  Contraindicated

27. Lactation ResourcesLactation Resources  BooksBooks – Thomas W. Hale.Thomas W. Hale. ““Medications andMedications and Mothers’ Milk” 2012, 15Mothers’ Milk” 2012, 15thth editionedition

28. Hale TW. Medications and Mothers' Milk, 2010;Hale TW. Medications and Mothers' Milk, 2010; 14th edition.14th edition. Dr. Hale’s Lactation Risk Category  L1 Safest  L2 Safer  L3 Moderately Safe  L4 Potentially Hazardous  L5 Contraindicated

29. Dr. Hale’s Lactation Risk CategoryDr. Hale’s Lactation Risk Category  L1L1 SafestSafest: Drug taken by larger # of breast: Drug taken by larger # of breast feeding women without any observedfeeding women without any observed adverse effects in infantadverse effects in infant  L2L2 SaferSafer: Drug studied in a limited # of: Drug studied in a limited # of breast feeding women without any observedbreast feeding women without any observed adverse events in infantsadverse events in infants  L3L3 Moderately SafeModerately Safe: No controlled trials in: No controlled trials in breast feeding women, but risk of untowardbreast feeding women, but risk of untoward effects is possibleeffects is possible

30. Dr. Hale’s Lactation Risk CategoryDr. Hale’s Lactation Risk Category  L3L3 Moderately SafeModerately Safe: No controlled trials in: No controlled trials in breast feeding women, but risk of untowardbreast feeding women, but risk of untoward effects is possibleeffects is possible OROR controlled studiescontrolled studies show only minimal non-threatening adverseshow only minimal non-threatening adverse effectseffects  L4L4 Potentially HazardousPotentially Hazardous: Positive: Positive evidence of risk to the breastfed infantevidence of risk to the breastfed infant OROR toto the breast milk production but benefitthe breast milk production but benefit outweighs the riskoutweighs the risk

31. Dr. Hale’s Lactation Risk CategoryDr. Hale’s Lactation Risk Category  L5L5 ContraindicatedContraindicated: Studies in: Studies in breastfeeding women have demonstratedbreastfeeding women have demonstrated significant and documented risk to the infant.significant and documented risk to the infant. Risk clearly outweighs benefits of breastRisk clearly outweighs benefits of breast feeding.feeding.

32. Values Used to Estimate Infant Drug Exposure  Milk to Plasma Ratio (M/P) – Ratio of the concentration of drug in mother’s milk divided by the concentration in the mother’s plasma – M/P <1 is preferred  Theoretical Infant Dose (TID) – Multiply the milk concentration x daily milk intake of the infant – Compared to the usual maintenance pediatric dose  Relative Infant Dose (RID) – Divide the infant’s dose via milk (mg/kg/day) by the mother’s dose (mg/kg/day) – Assumes daily milk intake of 150 ml/kg/day – RID<10% is considered safe – Exception: fluconazole, metronidazole (have a high RID but are non toxic)

33. Lactation ResourcesLactation Resources  InternetInternet – Dr. Hale’s BreastfeedingDr. Hale’s Breastfeeding Pharmacology pagePharmacology page (( http://www.neonatal.ttuhsc.edu/facthttp://www.neonatal.ttuhsc.edu/fact))

34. Lactation ResourcesLactation Resources  InternetInternet – U.S. National Library ofU.S. National Library of Medicine.Medicine. LactMedLactMed (http://toxnet.nlm.nih.gov/cgi-(http://toxnet.nlm.nih.gov/cgi- bin/sis/htmlgen?)/LACT)bin/sis/htmlgen?)/LACT)

35. LactMed

36. LactMed

37. Linezolid (Zyvox)

38. The Transfer of Drugs and Other Chemicals Into Human Milk Committee on Drugs Pediatrics 2001;108;776 CLINICAL REPORT The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics Hari Cheryl Sachs, MD, FAAP* and COMMITTEE ON DRUGS Pediatrics; originally published online August 26, 2013; DOI: 10.1542/peds.2013-1985

39. BeforeBefore Prescribing Drug Therapy in thePrescribing Drug Therapy in the Lactating WomanLactating Woman 1.1. Is drug therapy really necessary?Is drug therapy really necessary? 2.2. The safest drug should be chosen.The safest drug should be chosen. 3.3. If there is a possibility that a drug mayIf there is a possibility that a drug may present a risk to the infant, then considerpresent a risk to the infant, then consider measuring blood levelsmeasuring blood levels 4.4. Drug exposure in the infant may be limitedDrug exposure in the infant may be limited by timing of med and breastfeedingby timing of med and breastfeeding AAP Committee on Drugs. The transfer of drugs and other chemicalsAAP Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics 2001;108 (3):777into human milk. Pediatrics 2001;108 (3):777

40. AnalgesicsAnalgesics  Acetaminophen (Tylenol) is compatible with breastAcetaminophen (Tylenol) is compatible with breast feedingfeeding  Nonsteroidal antiinflammatory drugs (NSAIDS) –Nonsteroidal antiinflammatory drugs (NSAIDS) – ibuprofen is preferredibuprofen is preferred – Naprosyn, sulindac, piroxicam should be avoidedNaprosyn, sulindac, piroxicam should be avoided  Narcotic/Opiates – morphine, codeine, oxycodone,Narcotic/Opiates – morphine, codeine, oxycodone, and hydrocodone are compatible with breast feedingand hydrocodone are compatible with breast feeding – Meperidine (Demerol) should be avoidedMeperidine (Demerol) should be avoided

41. Narcotics/Opiates  Case controlled studies evaluating long term developmental outcomes are needed  Breastfeeding should be supported if: – “stable” and compliant with methadone or buprenorphine +/- naloxone (Subutex®, Suboxone®) – negative maternal urine toxicology test at delivery except for prescribed medications – plan to continue substance abuse treatment in the postpartum period – do not have medical contraindication to breastfeeding Breastfeeding Medicine 2009; 4(4):225-228

42. AntibioticsAntibiotics  Penicillins and cephalosporins are compatible with breastPenicillins and cephalosporins are compatible with breast feedingfeeding – Monitor infant for diarrhea (change in gut flora)Monitor infant for diarrhea (change in gut flora)  Tetracycline is compatible with breast feedingTetracycline is compatible with breast feeding – Calcium in breast milk limits absorption ; avoid doxycyline andCalcium in breast milk limits absorption ; avoid doxycyline and minocyclineminocycline  Quinolones have not been rated by AAPQuinolones have not been rated by AAP – Levaquin is compatible with breast feedingLevaquin is compatible with breast feeding  Trimethoprim-sulfamethoxazole (Bactrim) is compatible withTrimethoprim-sulfamethoxazole (Bactrim) is compatible with breast feedingbreast feeding – Not recommended in infants < 2 month (deplacement of bilirubin)Not recommended in infants < 2 month (deplacement of bilirubin)

43. AntidepressantsAntidepressants  Tricyclic antidepressants – little or no effect on breast feedingTricyclic antidepressants – little or no effect on breast feeding infantinfant – AAP lists as possible concern with exposure long-termAAP lists as possible concern with exposure long-term  Selective serotonin reuptake inhibitors (SSRIs) – generally 1Selective serotonin reuptake inhibitors (SSRIs) – generally 1stst choicechoice – Paroxetine (Paxil) or Sertraline (Zoloft) preferred toParoxetine (Paxil) or Sertraline (Zoloft) preferred to Fluoxetine (Prozac)Fluoxetine (Prozac)  Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) – Venlafaxine (Effexor)Venlafaxine (Effexor)  Take dose at bedtime to limit exposure to infantTake dose at bedtime to limit exposure to infant

44. Antidepressants: SSRIs and SNRIs  Limited to small case studies  Paroxetine and sertraline produced low RID 0.5-3%  Fluoxetine, citalopram, venlafaxine have variable RID near to equal 10%  Preference hierarchy: sertraline, paroxetine, citalopram, venlafaxine, fluoxetine  Watch for uneasy sleep, colic, irritability, poor feeding, drowsiness Breastfeeding Medicine 2008; 3 (1): 44-52

45. Relative Infant Dose (RID) of Commonly Prescribed Antidepressants Antidepressant Relative Infant Dose (%) Buproprion (Wellbutrin) 2 Citalopram (Celexa) 3-10 Desvenlafaxine (Khedezla) 5.5-8.1 Duloxetine (Cymbalta) <1 Escitalopram (Lexapro) 3-6 Fluoxetine (Prozac) <12 Fluvoxamine (Luvox) <2 Mirtazapine (Remeron) 0.5-3 Paroxetine (Paxil) 0.5-3 Sertraline (Zoloft) 0.5-3 Venlafaxine (Effexor) 6-9 Chad L et.al. Update on antidepressant use during breastfeeding. Canadian Fam Physician 2013; 59: 633-634.

46. Antiepileptic MedsAntiepileptic Meds  Phenytoin, Carbamazepine, and Valproic acid arePhenytoin, Carbamazepine, and Valproic acid are compatible with breast feedingcompatible with breast feeding – Caution in use due to risk for hepatotoxicityCaution in use due to risk for hepatotoxicity (Valproate)(Valproate)  Lamotrigine (Lamictal), Primadone (Mysoline),Lamotrigine (Lamictal), Primadone (Mysoline), Phenobarbital are compatible with breast feedingPhenobarbital are compatible with breast feeding – not preferred due to slow metabolism in the infantnot preferred due to slow metabolism in the infant resulting in sedationresulting in sedation  Levetiracetam (Keppra) and Topiramate (Topamax)Levetiracetam (Keppra) and Topiramate (Topamax) appear compatible with breastfeedingappear compatible with breastfeeding

47. Antiepileptic meds: Topiramate and Levetiracetam  5 mother child pairs on Topiramate – mean milk:plasma ratio 0.86 – Topiramate concentrations in infant were low – 4 of 5 mothers also taking carbamazepine (inducer)  8 women on Levetiracetam – Milk and plasma concentration equal – Levetiracetam concentrations in infants were low Ohman I et.al. Topiramate kinetics during delivery and lactation. Epilepsia 2002; 43: 1157-1160 Johannasen SI et.al. Levetiracetam concentrations in serum and breast milk at birth and during lactaction. Epilepsia 2005; 46: 775-777

48. AntihistaminesAntihistamines  All sedating antihistamines have theAll sedating antihistamines have the possibility of causing sedation in the infantpossibility of causing sedation in the infant  Sedating antihistamines (esp. withSedating antihistamines (esp. with decongestant) can decrease milk supplydecongestant) can decrease milk supply  Nonsedating antihistamines are compatibleNonsedating antihistamines are compatible with breast feedingwith breast feeding – Loratadine (Claritin) preferredLoratadine (Claritin) preferred

49. Blood Pressure MedsBlood Pressure Meds  Diuretics are compatible with breast feedingDiuretics are compatible with breast feeding – Avoid high dosesAvoid high doses  Beta blockers are compatible with breast feedingBeta blockers are compatible with breast feeding – Propranolol, metoprolol, and labetalol preferredPropranolol, metoprolol, and labetalol preferred – Atenolol, nadolol, and sotalol can lead to SE (hypotension,Atenolol, nadolol, and sotalol can lead to SE (hypotension, bradycardia, tachypnea)bradycardia, tachypnea)  Calcium channel blockers (CCBs) are compatibleCalcium channel blockers (CCBs) are compatible with breast feedingwith breast feeding – Nifedipine (Procardia) is preferredNifedipine (Procardia) is preferred  ACE inhibitors and ARBs must use with cautionACE inhibitors and ARBs must use with caution

50. Diabetes MedsDiabetes Meds  Insulin is compatible with breast feedingInsulin is compatible with breast feeding  22ndnd Generation sulfonylureas (eg. glyburide,Generation sulfonylureas (eg. glyburide, glipizide, glimeperide) are compatible with breastglipizide, glimeperide) are compatible with breast feedingfeeding  Metformin is compatible with breast feedingMetformin is compatible with breast feeding  Limited data with use of thioglitazones (eg.Limited data with use of thioglitazones (eg. AvandiaAvandia®®, Actos, Actos®®))  Monitor infants for symptoms of hypoglycemiaMonitor infants for symptoms of hypoglycemia

51. Diabetes Meds: Glyburide and Glipizide  Nonrandomized controlled study  Single dose of glyburide (5 or 10 mg, n=8)  Daily dose of glyburide or glipizide (5 mg; n=5)  No glyburide was found in milk  Mean infant exposure < 1.5%  Blood glucose levels were normal  Glyburide and glipizide compatible with breastfeeding Feig DS et.al. Transfer of glyburide and glipizide into breast milk. Diabetes Care 2005; 28:1851-5

52. Diabetes Meds: MetforminDiabetes Meds: Metformin  Prospective studyProspective study  61 breast fed, 50 formula fed infants61 breast fed, 50 formula fed infants  Evaluate growth, motor-social development orEvaluate growth, motor-social development or illnessillness  Median metformin dose 2.55 grams per dayMedian metformin dose 2.55 grams per day  6 months of life - no difference in weight, ht, motor-6 months of life - no difference in weight, ht, motor- social development, illness (psocial development, illness (p ≥ 0.06)≥ 0.06)  Mean infant exposure 0.28-1.08%Mean infant exposure 0.28-1.08%  Metformin safe in 1Metformin safe in 1stst 6 months of life6 months of life Glueck CJ et.al. J Pediatrics 2006; 148 (5): 628-632

53. Medications Contraindicated inMedications Contraindicated in Breast FeedingBreast Feeding  AntineoplasticsAntineoplastics  Immune suppressantsImmune suppressants  Ergot alkaloidsErgot alkaloids  GoldGold  Iodine/Radiocontrast mediaIodine/Radiocontrast media  Lithium carbonateLithium carbonate  Certain antibioticsCertain antibiotics  Social drugs and drugs of abuseSocial drugs and drugs of abuse

54. Minimizing Potential Risk to NursingMinimizing Potential Risk to Nursing Infants from Maternal MedicationsInfants from Maternal Medications  General ConsiderationsGeneral Considerations – Avoid drug therapy when possibleAvoid drug therapy when possible – Use topical therapy when possibleUse topical therapy when possible – Meds that are safe for use in the infant ARE generally safeMeds that are safe for use in the infant ARE generally safe for the breast-fed motherfor the breast-fed mother – Meds that are safe in pregnancy are NOT always safe inMeds that are safe in pregnancy are NOT always safe in breast-feedingbreast-feeding – Use reliable references for obtaining info on meds in breastUse reliable references for obtaining info on meds in breast milkmilk Spencer JP et. al. Medications in the Breast-Feeding Mother. AFPSpencer JP et. al. Medications in the Breast-Feeding Mother. AFP 2001,64:1202001,64:120

55. Minimizing Potential Risk to NursingMinimizing Potential Risk to Nursing Infants from Maternal MedicationsInfants from Maternal Medications  Medication dosingMedication dosing – Administer single daily dose meds justAdminister single daily dose meds just beforebefore thethe longest sleep interval for the infant, usually afterlongest sleep interval for the infant, usually after the bedtime feedingthe bedtime feeding – Breastfeed infant immediatelyBreastfeed infant immediately beforebefore med dosemed dose when multiple daily doses are neededwhen multiple daily doses are needed Spencer JP. Medications in the Breast-Feeding Mother.AFP, 2001:Spencer JP. Medications in the Breast-Feeding Mother.AFP, 2001: 64:12064:120

56. ConclusionConclusion  Healthcare providers should encourageHealthcare providers should encourage mothers to breast feedmothers to breast feed  Evidence supports most commonlyEvidence supports most commonly prescribed meds in breast feeding mothersprescribed meds in breast feeding mothers can be taken safelycan be taken safely  Utilize available lactation referencesUtilize available lactation references  Further help can be provided by yourFurther help can be provided by your lactation consultant and clinical pharmacistlactation consultant and clinical pharmacist

57. References 1. Buck, ML. Drugs in Pregnancy and Lactation: Literature an Resource Update. Pediatric Pharm., 2010;16 (1): 1-5. 2. Burkey BW. Evaluating Medication Use in Pregnancy and Lactation: What Every Pharmacist Should Know. J Pediatric Pharmacol Ther 2013; 18(3):247-258. 3. Chad L et.al. Update on Antidepressant Use During Breastfeeding. Canadian Family Physician, 2013; 59: 633-634. 4. Feig DS et. al. Oral Antidiabetic Agents in Pregnancy and Lactation: A Paradigm Shift? The Annals of Pharmacotherapy, 2007:41(7): 1174-1180. 5. Glatstein MM et. al. Use of Hypoglycemic Drugs During Lactation. Canadian Family Physician, 2009; 55: 371-373. 6. Glueck CJ et.al. Growth, Motor, and Social Development in Breast and Formula-fed Infants of Metformin-treated Women with Polycystic Ovarian Syndrome. J Pediatrics, 2006; 148(5):628-32. 7. Sachs et.al. AAP Committee on Drugs: The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics. Pediatrics, 2013; 132 (3): e796- e809. 8. Mathhew JL. Effect of Maternal Antibiotics on Breast feeding Infants. Postgrad Med Journal, 2004; 80:196-200.

58. References 9. Mortel M and Mehta SD. Systematic Review of the Efficacy of Herbal Galactogogues. Journal of Human Lactation,2013;29(2):154-162. 10. Pack AM. Therapy Insight: Clinical Management of Pregnant Women with Epilepsy. Nat Clin Pract Neurol, 2006; 2(4):190-200. 11. Wagner CL. Human Milk and Lactation. Medscape, 2012. 12. The Academy of Breastfeeding Medicine (ABM) Protocol Committee. ABM Clinical Protocol #18: Use of Antidepressants in Nursing Mothers. Breast Feeding Medicine, 2008;3(1):44-52. 13. The Academy of Breastfeeding Medicine (ABM) Protocol Committee. ABM Clinical Protocol #21: Guidelines for Breastfeeding and the Drug-Dependent Woman. Breast Feeding Medicine, 2009;4(4):225-228. 14. The Academy of Breastfeeding Medicine (ABM) Protocol Committee. ABM Clinical Protocol #9. Use of Galactogogues in Initiating or Augmenting the Rate of Maternal Milk Secretion. Breast Feeding Medicine, 2011;6(1):41-49.

59. Thank you!