Breastfeeding is recommended for mothers with special needs with some precautions. Cesarean delivery mothers should breastfeed within 4 hours of delivery to help establish lactation. Mothers with illnesses like heart disease, hepatitis B, or thyroid dysfunction can breastfeed with additional support and monitoring. Some medications are compatible with breastfeeding like warfarin, chloroquine, and category A and B drugs when the benefits outweigh the risks and amounts in breastmilk are minimal. Pumping and proper medication timing can minimize risk to infants from maternal medications and conditions.

1. Breas&eeding+:++
“Mothers+with+Special+Needs”

2. Objectives
Identifymotherswithspecial
needs
Providespecificsupporttothese
mothers
Preventbreastfeedingproblems
inmotherswithspecialneeds

3. Motherswith
specialneeds
Cesareandelivery/anesthesia
Twins
Separation/Employment
Maternaldiseasesorillness
Druguse

4. Cesareansection
HelpsmothertoBFaftereffectsof
anesthesiawearsofforwithin4
hoursofdelivery,whicheverisearlier
Comfortablepositionandsupport
Explainthattheremaybeslight
delayedestablishmentoflactation
followingsurgery

5. Cesareansection!
Roominginoffersseveraladvantages.
Somehospitalshavepoliciesthatrequirethat
babiesbornviac-sectionspendthefirst24hours
inthenurseryunderobservation,althoughthe
trendinmosthospitalsoverthepastfewyearshas
beentoseparatemothersandbabiesaslittleas
possible
Electricalpumping asapafterbirthandevery
coupleofhoursafterthat.
Pumping willhelptostimulatemilksupply,
prevent engorgement,andprovidevaluable
colostrumthatcanbefedtothebabyinthe
nurseryuntilmotherandbabycanbetogether
again.

6. Multiplebirths
“Demandandsupply”
Simultaneousoralternate
Additionalhelp
PromoteexclusiveBF

7. Multiplebirths!
Manytwinsandtripletsare
premature.
Breastmilkisparticularlygoodfor
thembecauseitismoreeasily
digestedandtoleratedthanformula
milkandhelpstheunderdeveloped
guttomature.
Butthesebabiesmaynotbeableto
breastfeedatfirst,somayneedto
expressmilkandhaveitfedthrough
Ryle’stubeorbykatoriandspoon.

8. Employedmothers
ExclusivelyBFforaslongas
possible
Extendmaternityleaveforaslong
aspossible–now6months
Starthomemadecomplementary
feeds
Onresumingwork,maximizeBF
schedulewhenathome
Expressmilkforcomfortand
production
Feedwithkatoriandspoon
!

9. Employedmothers!
StudyinTaiwanconcludedthatahigher
educationlevel(oddsratio[OR]=2.66),
lowerworkload(8workhours/day)
(OR=2.66),lactationroomwithdedicated
space(OR=2.38),useofbreastpumping
breaks(OR=61.6),andencouragement
fromcolleagues(OR=2.78)andsupervisors
(OR=2.44)tousebreastpumpingbreaks
weresignificantpredictorsofcontinued
breastfeedingformorethan6monthsafter
returningtowork
Tsai+SY+:Breas&eed+Med.2013+Apr;8:210C6.+

10. Employedmother:
Partner'ssupport
Thepartner'sinitialsupportofthechoiceto
breastfeedandencouragementtousethe
lactationroomandmilkexpressionbreaks
andthemother'sperceptionofthepartner's
supportforbabycareweresignificant
predictorsoftheintentiontocontinueto
breastfeedafterreturningtowork.
Tsai+SY+Breas&eed+Med.2014+May;9(4):222C30.++

11. Sickmothers
Maternaldiseasenotalwaysa
contraindicationforBF
TheyneedadditionalsupporttoBF
successfully
Transfermother–infantpair
Expressfrequentlytofeedbabyand
maintainproductionwhenseparated

12. Heartdisease
Breastfeedingwithheldifmother
infailure,tillactivefailure
controlled
Encourageexpressionofbreast
milk
Digoxin
Antiarrhythmics
Anticoagulants
Lookforcongenitalheartdisease
inbaby

13. Heartdisease!
Becauseofthelowlevelsof
digoxininbreastmilk,amounts
ingestedbytheinfantaresmall
andwouldnotbeexpectedto
causeanyadverseeffectsin
breastfedinfants.
Ifthemotheristoreceivedigoxin
intravenously,avoidanceof
breastfeedingfor2hoursafterthe
dosewilllessenthedosetheinfant
receives

14. Antiarrhythmic drugs
Thereisalsoapotentialforadverse
effectsininfantsexposedto
antiarrhythmicdrugsduringbreast
feeding.
Generally,theamountof
antiarrhythmicdrugexcretedinto
breastmilkissmall.Thereareonly
fewantiarrhythmicdrugs(e.g.,
atenolol,amiodarone)whichare
contraindicatedforthenursing
mother

15. Warfarin
Warfarinwasmeasuredwithasensitiveand
specificmethodintheplasmaandbreastmilk
of13mothers.Lessthan0-08micronmol
warfarinperlitre(25ng/ml)ofbreastmilk
wasfoundineachinstance.Sevenofthe
motherswerebreast-feedingtheirinfants,in
noneofwhomwaswarfarindetectedinthe
plasma;furthermore,inthreetheBritish
correctedratiooftheplasmawasappreciably
lessthanthatofthemotherandwaswithin
theexpectedrange.
Concludedthatnursingmothersgiven
warfarinmaysafelybreast-feedtheirinfants.!
MLOrmeetal:BrMedJ 1977;1:1564

16. Anticoagulants
Dailyinjectionsofheparinoralow
molecularweightheparinoid
(enoxaparin,dalteparinortinzaparin).
Thesedrugsdonotpassintobreast
milkinanysignificantamountasthe
moleculesareverylargeandthedrugs
haveverypoororalbioavailability
JonesWBreastfeedingandMedication2013Routledge

17. Theherpesvirusisnottransmitted
throughbreastmilk.
Couldgetinfectedbytouchinga
blisterorsoreonbreast,mouth,or
otherareaofbody.
Herpessimplex!

18. Aherpesblisteronbreastthat's
closenippleorareola,don'tnurse
fromthatsideuntiltheareahas
completelyclearedup.
Toexpressorpumpmilkfrom
infectedbreastwithouttouching
thesoreandfeedthebaby.
Antiviralacyclovirorvidarabineto
fighttheherpesinfectionandare
generallyconsideredsafeduring
breastfeeding,
Herpessimplex!

19. HepatitisB
NotacontraindicationforBF
Activeandpassiveimmunisation
atbirth

20. InfantsmayacquireHBVinfection
throughbreastfeeding,becausesmall
amountsofHepatitisBsurface
antigen(HBsAg)havebeendetected
insomesamplesofbreastmilk.
Afollowupstudyof147infantsborn
tomothersknowntobecarriersof
HBVinTaiwanfoundnoevidenceof
HBVinfectionin92childrenwhowere
breastfedcomparedto55whowere
bottlefed.
• WooDetal:ArchChildDis,1979;54:670-75
HepatitisB!

21. AstudyinBritain,involving126
subjects,alsoshowednoadditional
riskforbreastfedversusnonbreastfed
infantsofcarriermothers
Expertsonhepatitis,however,dohave
concernsthatbreastpathologysuchas
crackedorbleedingnipplesorlesions
withserousexudatescouldexposethe
infanttoinfectiousdosesofHBV.
WooDetal:ArchChildDis,
1979;54:670-75
HepatitisB!

22. HepatitisB
WHOrecommendsthatallinfants
receivehepatitisBvaccineaspartof
routinechildhoodimmunization.
Wherefeasible,thefirstdoseshould
begivenwithin48hoursofbirthoras
soonaspossiblethereafter.
Thiswillsubstantiallyreduceperinatal
transmission,andvirtuallyeliminate
anyriskoftransmissionthrough
breastfeedingorbreastmilkfeeding.
Immunizationofinfantswillalso
preventinfectionfromallothermodes
ofHBVtransmission.

23. CMVInfection!
!
Recentlybecomeamatterofsomedebate.
Acquiredbythenewbornmainlyviabreast
milkandthoughthishaspracticallyno
consequencesintermnewborns,itmay
causeseveresymptomaticdiseasein
pretermnewborns.
AlmostallCMV-seropositivewomen
eliminatethevirusviatheirmilk;freezing
breastmilkat
-20degreesCandpasteurizationmay
respectivelyreduceoreliminatetheviral
load.
StronaJ+M+et+al+:J+Chemother.2007+Oct;19+Suppl+2:49C51+

24. Diabetes
Insulinisinactivatedbybaby’s
digestivesystem,causingnoharm
tothebaby
ContinueBF

25. Diabetes!
Breastfeedinghasnumerous
advantagesformotherswithdiabetes
andtheirbabies.Nursingmothershave
lowerinsulinrequirementsandbetter
controloftheirbloodglucose;
breastfedbabiesmayhavealowerrisk
ofdevelopingdiabetesthemselves
Diabetesappearstoslowmilk
production;
Insulinplaysacentralroleinstarting
andmaintainingbreastfeeding.This
mayexplain,inpart,whymotherswith
diabetesareusuallyslowertoproduce
milkintheearlydaysafterdelivery

26. +
MINIMIZINGRISKTOINFANTS
FROMMATERNAL
MEDICATIONS

27. !!!CategoryA: Adequate,well-controlledstudiesinpregnant
womenhavenotshownanincreasedriskoffetal
abnormalitiestothefetusinanytrimesterofpregnancy
CategoryB: Animalstudieshaverevealednoevidenceof
harmtothefetus,however,therearenoadequateand
well-controlledstudiesinpregnantwomen OR Animal
studieshaveshownanadverseeffect,butadequateand
well-controlledstudiesinpregnantwomenhavefailedto
demonstratearisktothefetusinanytrimester.
CategoryC: Animalstudieshaveshownanadverseeffect
andtherearenoadequateandwell-controlledstudiesin
pregnantwomen OR Noanimalstudieshavebeen
conductedandtherearenoadequateandwell-controlled
studiesinpregnantwomen.

28.
CategoryD: Adequatewell-controlledor
observationalstudiesinpregnantwomenhave
demonstratedarisktothefetus.However,the
benefitsoftherapymayoutweighthepotential
risk.Forexample,thedrugmaybeacceptableif
neededinalife-threateningsituationorserious
diseaseforwhichsaferdrugscannotbeusedor
areineffective.
CategoryX: Adequatewell-controlledor
observationalstudiesinanimalsorpregnant
womenhavedemonstratedpositiveevidenceof
fetalabnormalitiesorrisks.Theuseoftheproduct
iscontraindicatedinwomenwhoareormay
becomepregnant.

29. Principlesof
druguse
duringlactation
Isthedrugnecessary?
Canalternativedrugsobtain
equivalentresults?
Donottryneworexperimental
drugsforthefirsttimeinlactation
Mostdrugsareexcretedinsmall
quantitiesinthebreastmilk
Withholdfeedingtemporarilyin
contraindicateddrugs

30. Medicationdosing
Administersingledaily-dosemedicationsif
possible
BFimmediatelybeforemedicationdose
whenmultipledailydosesareneeded
Avoidfeedingatpeakdruglevels,usually1
to3hoursafteringestion,
Takedrugjustbeforethebaby’slongest
sleepperiod,usuallybedtimefeeding

31. Analgesics
MedicationEffect
withBF
Comment
Acetaminoph
en
Safe
IbuprofenSafe
AspirinUsewith
caution
Use
alternative

32. Tuberculosis(TB)!
Breastfeedingshouldbecontinued
intheseneonatesandisolationis
recommendedonlytillmotheris
infectious,hasmultidrugresistant
tuberculosisornonadherentto
treatment.
BCGvaccineisrecommendedat
birthoraftercompletionof
prophylaxis(3-6months)inall
neonates.
HemaMittaletalIndianJMedRes.2014Jul;140(1):
32–39

33. IAPguidelinesforinfantsbornto
motherswithTB
Initiateandcontinueexclusive
BF
BCGatbirth
INH5mg/kg/day
Rifampicin10mg/kg/day
Evaluateafter3months
Clinically
MT
Xraychest
TreataccordinglywithfullAKT

34. Anti-tubercularagents
MedicationEffect
withBF
Comment
Rifampicin,
Strepto,INH,
PZ
Safe
EthambutolUsewith
caution
Ocular
effects
Pyridoxine Usewith
caution
May
suppress
lactation

35. Thyroidmedications
MedicationEffectwithBFComment
MethimazoleContraindicatedCansuppress
infant’s
thyroid.Use
propyluracil&
monitor
CarbimazoleContraindicated

36. ThyroidDysfunction
Riskfactorsfordelayedlactationor
insufficientmilkproduction.
Bucksheeetalreportedthatmotherswith
hypothyroidismhadalactationdeficiency
rateof19.2%despitehormonereplacement
treatmentduringpregnancy. .

37. ThyroidDysfunction
Improvinglactationoutcomes:
Impairedreleaseofmilk,ratherthan
impairmentofmilksynthesis,appearsto
bethegreaterobstaclewithbothhyper-
andhypothyroidism.

38. ThyroidDysfunction
Withoutadequatemilkremoval,increased
concentrationsoffeedbackinhibitorof
lactationproteininresidualmilktrigger
downwardregulationofmilksynthesis,
resultinginsuppressedmilkproduction
andeventualinvolutionofthegland.
Thus,improvingmilkreleasemayimprove
lactationwhenthyroidhormonesare
dysfunctional.

39. Malaria
Malariaparasitescannotbetransferredviabreast
milk.However,thereisevidencethatsome
antimalarialdrugscanpassthroughbreastmilk,
withunknowneffectsontheinfant;assuch,itis
notrecommendedthatbreastfeedingmothers
takecertainantimalarialdrugs.
Chloroquineandproguanilareconsidered
compatiblewithbreastfeeding.

40. Antimalarials!
Limitedinformationindicatesthatamaternal
doseof200mgofartesunateorallyproducedlow
levelsinmilkandwouldnotbeexpectedtocause
anyadverseeffectsinbreastfedinfants,especially
iftheinfantisolderthan2monthsorweightof5
kgormore.
Withholdingbreastfeedingfor6hourafteradose
shouldmarkedlyreducethedosetheinfant
receives

41. Antimalarial
Averysmallamountofchloroquine
passesintobreastmilk.Thissmall
amountofdrugwillnotharminfant,but
itwon'tbeenoughdrugtoprotect
againstmalaria.Childrentakentoa
malaria-riskareashouldhavetheirown
antimalarialdrug.

42. Antimalarials
MedicationEffectwithBFComment
ChloroquineSafe
QuinineUsewithcautionChloroquine
preferred
Artemether
Artesunate
SafeNotoxic
effectsfound
MefloquineContraindicated

43. Antihypertensives
MedicationEffectwith
BF
Comment
AlphamethyldopaSafe
NifedipineSafe
HydralazineSafe
Magnesium
sulphate
Usewith
caution
CNS,respiratory
depression
DiureticsSafe

44. Antihypertensives!!
MedicationEffectwithBFComment
ACEinhibitorsBestavoided
Betablockers
includinglabetolol
Safe
PropranololSafe
AtenololBestavoidedPropranolol,
labetolol,
metoprolol
preferred

45. Diabetes
MedicationEffectwithBFComment
SulfonylureasContraindicated
InsulinSafe
MetforminSafe

46. Antibiotics!!!
MedicationEffectwithBFComment
ChloramphenicolBestavoidedIdiosyncraticreaction
CiprofloxacinUsewithcautionMoredatarequired
TetracyclineBestavoidedDentalstaining,
abnormalbonegrowth
MetronidazoleAvoidin1stmth
postpartum
Carcinogenicityin
animalstudies

47. An%bio%cs!
MedicationEffectwithBFComment
PenicillinsSafeunless
allergy
AltersGIflora–diarrhea
AminoglycosidesSafePoorlyabsorbedfromGIT
CephalosporinsSafeAltersGIflora–diarrhea
SulfonamidesBestavoidedPotentialtodisplace
bilirubinfromalbumin,risk
ofhemolysis&G6PDdef

48. Antimalignancy,Cytotoxic&Radioactive
Drugs
CategoryX
BFContraindicated
Raresituationinobstetrics
MothergivenMethotrexateforadherent
placentaorectopicpregnancy
WithholdBFfor72hoursafterlastdose

49. InfantfeedinginHIVpositivemothers:
FactorsaffectingtransmissionthroughBF
Maternalfactors:
– Advanceddisease-lowCD4+counts-
increasedviralloadinbreastmilk
– Recentinfection
– Breastabscess/Mastitis/Subclinicalmastitis
• Ingestionofinflammatorycells
• Increasedviralload
– Nipplelesions:soresandcracks
Infant:
– Oralcandidiasis<6months

50. Options
Notgivingbreastfeedingatall
– Givingexclusivereplacementfeeding
(ERF)
Givingexclusivebreastfeeding(EBF)and
makingitsafer:
– Givingbreastfeedingforshorter
duration
– GivingEBFandART
• Toinfant
• Tomotherandinfantboth

51. Informedchoice
CurrentWHO/UNAIDS/UNICEFguidelines
recommend“informedchoice”andfull
supportintheirdecision
Mostappropriateinfantfeedingoption
dependsonindividualcircumstances
– Mothershealth
– Localsituations
– Healthservicesavailable
– Counselingandsupportavailable

53. NACORecommendations2015
Whereexclusivereplacementfeedingis
AFASS-acceptable,feasible,affordable,
sustainableandsafe,avoidanceofallbreast
feedingisrecommended
Incasereplacementfeedingisnotpossible,
exclusivebreast-feedingforfirstsixmonths
oflifeisrecommended(notlongerthan6
months)
Atthetimeofweaninggoodquality
complementaryfoodshouldbeintroduced
ensuringadequateamountofenergy,
proteinsandmicronutrients.

54. Conclusion
Breastfeedingisthebestoptionfor
infants.
However,incertainsituationsitis
challengingformotherstobreastfeed
theirinfants.
Identifyingthesemothersandproviding
themwithspecificsupportcanreallyhelp
themtopreventbreastfeedingproblems.

56. An%arrhythmic!drugs!are!medicines!that!correct!irregular!heartbeats!!
and!slow!down!hearts!that!beat!too!fast.+
!
• There!is!also!a!poten%al!for!adverse!effects!in!
infants!exposed!to!an%arrhythmic!drugs!
during!breast!feeding.!
• !Generally,!the!amount!of!an%arrhythmic!drug!
excreted!into!breast!mild!is!small.!There!are!
only!few!an%arrhythmic!drugs!(e.g.,!atenolol,!
amiodarone)!which!are!contraindicated!for!
the!nursing!mother!

57. Psycholep%cs!
MedicationEffectwithBFComment
HaloperidolUsewith
caution
LithiumContraindicated
PhenothiazinesUsewith
caution

58. Infant!feeding!in!HIV!posi%ve!mothers!
• 90G95!%!new!infec%ons!in!children!result!from!
PTCT!
• >!80%!of!them!in!resource!poor!countries!

59. Categoriesofdrugs
!+Thesedrugsmaybeadministered
Arenotexcretedinbreastmilk
Arenotabsorbedbytheinfant
Produceverylowlevelsininfantwithno
apparenteffects
Adverseeffectminor,reversibleorof
doubtfulassociationandclinically
insignificant

60. Categoriesofdrugs
?Thesedrugscanbeadministeredonly
whenmother&infantcanbemonitored
Minoradverseeffectsdescribedormay
beanticipatedontheoreticalgrounds
Insufficientinformationrelatingto
breast-feedingavailabletoallow
classificationasasafedrug
Maysuppresslactation

61. Categoriesofdrugs
! These+drugs+are+unsuitable!!
!!
Seriousadverseeffectshavebeen
described
Seriousadverseeffectsmaybe
anticipatedontheoreticalgrounds

62. • !INH!prophylaxis!is!recommended!in!the!neonate!if!the!mother!has!
received!treatment!for!<2!wk,!or!those!who!are!on!therapy!for!>2!wk!but!
are!sputum!smear!posi%ve.!
• !In!all!other!situa%ons!there!is!no!need!of!therapy.!!
• American!Academy!of!Pediatrics!(AAP)!recommends!INH!prophylaxis!to!
all!neonates!of!mothers!who!are!diagnosed!with!tuberculosis!in!the!
postpartum!period!and/or!aRer!the!commencement!of!breasSeeding!has!
started!as!these!newborns!are!considered!poten%ally!infected!
• Dura%on!of!prophylaxis!is!guided!by!skin!tes%ng!by!Mantoux!test!at!three!
months!in!New!Zealand22!and!by!WHO21,!MERCK!Manual23!and!AAP!or!at!
6!months!in!Malaysia!and!South!Africa.!!
• If!Mantoux!test!is!nega%ve,!prophylaxis!is!stopped.!However,!if!Mantoux!
test!is!posi%ve!and!evidence!of!disease!is!found,!ATT!is!started.!!
• If!there!is!no!evidence!of!disease!in!Mantoux!posi%ve!neonates,!then!INH!
may!be!given!for!six!monthsor!9!months23.!IAP!does!not!comment!on!
maternal!treatment!or!Mantoux!test!and!suggests!isoniazid!therapy!to!all!
newborns!for!at!least!6G9!months!or!a!minimum!for!three!months!un%l!
mother!is!culture!nega%ve.!!
• There!is!also!a!varia%on!in!the!dose!recommended!for!prophylaxis!with!5!
mg/kg,!15!mg/kg,!and!10!mg/kg.!

63. • Nutri%on!and!breasSeeding!G!Support!for!breasSeeding!is!crucial!for!the!
survival!of!the!newborn.!Human!milk!in!addi%on!to!providing!nutri%on!
has!immunological!benefits!and!all!efforts!to!con%nue!breasSeeding!in!
newborns!with!mothers!having!tuberculosis!should!be!made.!In!case!of!
maternal!sickness!or!if!mother!is!smear!posi%ve!at!the!%me!of!delivery!or!
mothers!with!MDR!TB,!when!breasSeeding!may!not!be!possible,!
expressed!breast!milk!feeding!is!an!alterna%ve,!with!personal!hygiene.!
AAP!recommends!con%nued!feeding!with!expressed!milk!in!mothers!with!
pulmonary!TB!who!are!contagious,!untreated!or!treated!(<!3!wk)!with!
isola%on!
• !WHO!recommends!feeding!under!all!circumstances,!however,!close!
contact!with!the!baby!should!be!reduced.!Malaysian!Thoracic!Society!
recommends!that!if!mother!is!contagious,!efforts!should!be!made!to!use!
expressed!maternal!milk!for!feeding.!There!is!a!paucity!of!scien%fic!
literature!on!the!increased!risk!of!neonatal!transmission!by!breasSeeding!
in!the!presence!of!factors!such!as!infec%on!with!resistant!organisms!
(mul%ple!or!extensive!drug!resistance!or!coGinfec%on!with!human!
immunodeficiency!virus.!
• !First!line!ATT!is!secreted!in!milk!in!small!quan%ty!and!causes!no!adverse!
effect!on!the!child!

64. ThyroidDysfunction
• Improving*lacta/on*outcomes.!Impaired!release!of!milk,!rather!than!
impairment!of!milk!synthesis,!appears!to!be!the!greater!obstacle!with!
both!hyperG!and!hypothyroidism.!Without!adequate!milk!removal,!
increased!concentra%ons!of!feedback!inhibitor!of!lacta%on!protein!in!
residual!milk!trigger!downward!regula%on!of!milk!synthesis,!resul%ng!in!
suppressed!milk!produc%on!and!eventual!involu%on!of!the!gland.!Thus,!
improving!milk!release!may!improve!lacta%on!when!thyroid!hormones!
are!dysfunc%onal.!Exogenous!pitocin!(i.e.,!pitocin!nasal!spray)!might!
provide!the!oxytocin!necessary!to!eject!milk.!Massaging!the!breast!from!
the!chest!toward!the!nipple!prior!to!feeding!may!make!more!milk!
available!to!baby.!Breast!compression,!which!mechanically!increases!
internal!pressure,!may!also!help!to!propel!milk!from!the!breast!during!the!
feed.!!Galactogogues!would!be!effec%ve!only!in!the!presence!of!a!
func%oning!milk!ejec%on!reflex!and!will!work!best!when!thyroid!
hormones!are!in!balance.!They!should!be!considered!suppor%ve,!not!firstG
line!therapy,!but!may!be!useful!adjunct!therapy!when!milk!produc%on!
has!suffered.!

65. Anticoagulants
MedicationEffectwith
BF
Comment
HeparinSafeDoesnot
entermilk
Synthetic
heparin
Usewith
caution
Infant
coagulopathy
WarfarinSafe

66. amiodarone!
• This!medica%on!is!used!to!treat!certain!types!of!serious!(possibly!
fatal)!irregular!heartbeat!(such!as!persistent!ventricular!fibrilla%on/
tachycardia).!It!is!used!to!restore!normal!heart!rhythm!and!maintain!a!
regular,!steady!heartbeat.!Amiodarone!is!known!as!an!an%Garrhythmic!
drug.!!
• Infant!serum!levels!of!the!drug!plus!metabolite!range!from!14!to!74%!
of!simultaneous!maternal!levels,!with!the!higher!values!reflec%ng!
transplacental!passage!of!the!drug.[2][3][4]!In!addi%on!to!possible!
cardiac!effects,!these!compounds!contain!a!large!amount!of!iodine!
which!may!be!released!during!metabolism.!Thyroid!dysfunc%on!was!
reported!in!one!breasSed!infant.!Even!if!the!drug!were!discon%nued!
at!birth,!the!mother!would!con%nue!to!excrete!amiodarone!and!its!
metabolite!(and!possibly!large!amounts!of!iodine)!into!breastmilk!for!
days!to!weeks.!
• Some!inves%gators!believe!that!breasSeeding!can!be!undertaken!
during!maternal!amiodarone!use!with!periodic!monitoring!of!infant!
cardiac!and!thyroid!func%on!status,[5][6]!

67. • Most!commonly!used!drugs!are!rela%vely!safe!for!breasSed!babies.!The!
dose!received!via!milk!is!generally!small!and!much!less!than!the!known!
safe!doses!of!the!same!drug!given!directly!to!neonates!and!infants.!
• Drugs!contraindicated!during!breasSeeding!include!an%cancer!drugs,!
lithium,!oral!re%noids,!iodine,!amiodarone!and!gold!salts.!
• An!understanding!of!the!principles!underlying!the!transfer!into!breast!milk!
is!important,!as!is!an!awareness!of!the!poten%al!adverse!effects!on!the!
infant.!
• Discussion!with!the!mother!about!the!possibility!of!either!nega%ve!
product!informa%on!or!illGinformed!advice!from!others!will!reduce!the!
confusion!and!anxiety!that!may!be!generated.!
• Good!resources!about!medicines!and!breasSeeding!are!available!and!
include!stateGbased!medicines!informa%on!services.!

68. Drug!Comment!
Drug!Comment!
Amiodarone!Long!halfGlife,!iodineGcontaining!
molecule,!and!may!affect!thyroid!
func%on!in!infant!
An%neoplas%cs!Leukopenia,!bone!marrow!
suppression!
Gold!salts!Rash,!nephri%s,!haematological!
abnormali%es!
Iodine!High!doses!(>150!micrograms!daily)!
lead!to!risk!of!infant!hypothyroidism!
Lithium!BreasSeeding!only!feasible!with!
rigorous!monitoring!
Radiopharmaceu%cals!Contact!obstetric!informa%on!service!
Re%noids!(oral)!Poten%al!for!serious!adverse!effects!
Examples+of+drugs+contraindicated+in+breas&eeding!
!

69. • Mother!to!neonatal!transmission!of!disease!is!well!known!via!transplacental!
transmission!through!the!umbilical!vein!to!the!fetus,!through!the!inges%on!of!
infected!amnio%c!fluid.!Early!detec%on!is!challenging,!because!of!the!nonspecific!
nature!of!the!signs!and!symptoms!in!tuberculosis!during!pregnancy!and!infancy.!
The!degree!of!clinical!suspicion!is!the!essen%al!component!of!diagnosis.!
Furthermore,!it!generally!has!a!difficult!treatment!and!it!should!not!be!delayed!
while!wai%ng!for!diagnos%c!test!results.!Prompt!iden%fica%on!and!proper!
treatment!regimens!for!congenital!tuberculosis!strongly!relate!with!enhanced!
outcomes.!
• Tuberculosis!in!the!neonatal!period!classically!has!been!divided!into!two!types:!
congenital!and!postnatally!acquired.!Congenital!tuberculosis!was!first!described!by!
Beitzke!in!1935!based!on!autopsy!review.!Essen%al!diagnos%c!element!included!
isola%on!of!Mycobacterium!tuberculosis!from!the!infant!and!either!a!primary!
hepa%c!complex!or!other!discoveries!consistent!with!TB!disease!in!the!first!days!
aRer!birth!(excluding!postnatal!exposure)![6].!
In!1994,!Cantwell!et!al.!suggested!revised!criteria.!The!main!criterion!
con%nues!to!be!referred!throughout!the!first!week!of!life!in!newborn!infants!
by!the!iden%fica%on!of!Mycobacterium!tuberculosis!infec%ous!lesions.!!

70. • The!second!main!route!of!infec%on!seemed!more!probable!in!five!
case!reports!studies!that!we!explored!in!those!studies!repor%ng!that!
the!pa%ent!had!no!liver!damage!depar%ng,!proven!by!the!absence!of!
liver!enlargement!with!result!of!normal!liver!func%on.!But!respiratory!
and!intes%nal!symptoms!were!present.!The!chest!radiographic!results!
showed!increased!pulmonary!marking!and!bilateral!pulmonary!
infiltrates.!Abdominal!radiographic!has!shown!a!nonspecific!intes%nal!
dilata%on!

71. • Summary+of+Use+during+LactaJon+
• With!healthy,!fullGterm!infants!it!appears!
acceptable!to!use!sulfamethoxazole!during!
breasSeeding!aRer!the!newborn!period.!Un%l!
further!data!are!accumulated,!alternate!agents!
should!probably!be!used!in!jaundiced,!ill,!stressed!
or!premature!infants,!because!of!the!risk!of!
bilirubin!displacement!and!kernicterus.!
Sulfamethoxazole!should!be!avoided!while!
breasSeeding!a!G6PDGdeficient!infant!

72. • Pyridoxine!is!frequently!used!in!combina%on!with!other!B!vitamins!in!vitamin!B!complex!products.!
!
You!may!remember!a!prescrip%on!medica%on!called!Bendec%n!that!was!used!for!morning!sickness!in!pregnancy.!
Bendec%n!contained!pyridoxine!and!a!sleepGinducing!an%histamine!called!doxylamine.!The!makers!of!Bendec%n!
took!it!off!the!market!in!1983!because!they!were!running!up!expensive!legal!bills!in!defense!of!their!product.!
Opponents!charged!it!might!be!responsible!for!birth!defects.!Meanwhile,!a!product!called!Diclec%n!that!is!similar!
to!Bendec%n!remained!available!in!Canada,!and!there!was!research!showing!that!neither!pyridoxine!nor!
Bendec%n!seems!to!cause!birth!defects!in!animals.!ARer!Bendec%n!was!removed!from!the!market,!there!was!no!
reduc%on!in!birth!defects,!but!hospitaliza%on!rates!for!pregnancyGrelated!nausea!and!vomi%ng!doubled.!
!

73. Herpessimplex
Infectiousforfirst5days
TemporarilydiscontinueBFfrom
affectedside
BFfromunaffectedside
Expressmilktomaintainproduction
BeginBFafterlesionheals
Maintainstricthandwashing

74. CMV
Riskoftransmissionfromapositiveor
carriermothertobabythroughbreastmilk
Weighriskofotherinfectionswithtopfeeds
againsttheriskoftransmissionofinfection
throughBF

75. US!FDA!drug!classifica%on!
Majority!of!drugs!are!category!C!
A!!Controlled!studies!show!no!risk!!!!!0.7+
B!!No!evidence!of!risk!in!humans!!!!!!!19+
C!!Risk!cannot!be!ruled!out!!!!!!!!!!!!!!!66+
D!!Posi%ve!evidence!of!risk!!!!!!!!!!!!!!!!7+
X+!Contraindicated!in!pregnancy!!!!!!!!!7+

76. Medicationselection
Choosemedicationswiththeshortesthalf-
lifeandhighestprotein-bindingability
Choosemedicationsthatarewell-studiedin
infants
Choosemedicationswiththepoorestoral
absorption
Choosemedicationswiththelowestlipid
solubility

77. Hypertension
Delayedfeeding
Supportandencouragement
Anticonvulsants
-Magnesiumsulphate
-Barbiturates
-Benzodiazepines
Antihypertensives
-Alphamethyldopa
-Calciumchannelblockers
-Betablockers

78. PsychiatricDisorders
Knowncaseofdepressionorpsychosis
Postpartumdepressionorpsychosis
Behavioralproblems-supervision&support
Infantsofmothersonanticonvulsantsmaydevelop
drowsiness
Itisessentialthatmotherstaketheirmedication
Dangeroustochangeantiepilepticmedicines
suddenly
Breastfeedingisusuallypossible,buttheinfant
mustbemonitored
Doseshouldbekeptaslowaspossiblewithinthe
effectivetherapeuticrange

79. Anticonvulsants!
Cautionagainstpolypharmacy
MedicationEffectwith
BF
Comment
PhenobarbitoneSafeMonitorforlethargy,drowsiness,
poorsucklingandpoorweightgain
DiazepamSafeSedation
PhenytoinSafeCyanosis,methemoglobinemia
ValproateSafeinlow
dose
Safetyinhighdoses?Jaundice
Carbamazepine?SafeJaundice,drowsiness,poorsuckling,
vomiting,poorweightgain

80. Antidepressants
MedicationEffectwithBFComment
TricyclicsSafe
SSRIs,
Fluoxetine
Insufficient
informationabout
safetyinBF
DoxepinContraindicated

81. InfantfeedinginHIV
positivemothers:
Factorsaffectingtransmission
throughBF
Statusofmaternaldisease
Durationofbreastfeeding
Exclusivevsmixedfeeding
Breastconditions
Breastmilkcharacteristics
Infantconditions

82. Transmission
Characteristicsofbreastmilk:
– Lowerconcentrationoflactoferrin,
lysozymes,epidermalgrowthfactor,IgM,IgA
increasetherisk
Durationofbreastfeeding&transmission
• 0.7%/mofor1-6months
• 0.6%/mofor6-12months
• 0.3%/mofor12-18months
• 0.2%/mofor18-24months

83. !
AFASS
Acceptable:Motherperceivesnoproblemin
acceptingreplacementfeeding(stigma)
Feasible:Motherhasadequatetime,knowledge,
skills,resources,andsupporttopreparemilk
andfeedupto12times/day
Affordable:Familycanbearthecostswithout
harmingthehealthandnutritionoffamily
Sustainable:Availabilityofacontinuoussupply
forsafereplacementfeedingfor1yearormore
Safe:Feedsarecorrectly&hygienicallyprepared+

84. Tuberculosis
(TB)
Aglobaldiseasewithincreaseinconcern
withgrowingmorbidityandmortality
afterdrugresistanceandco-infection
withHIV.
Mothertoneonataltransmissionof
diseaseiswellknown.
Currentrecommendationsregarding
managementofnewbornsofmothers
withtuberculosisarevariableindifferent
countriesandhavelargegapsinthe
knowledgeandpractices.

85. Tuberculosis
(TB)
Congenitaltuberculosisisdiagnosed
byCantwellcriteriaandtreatment
includesthreeorfouranti-tubercular
drugregimen.
Prophylaxiswithisoniazid(3-6
months)isrecommendedinneonates
borntomotherwithTBwhoare
infectious.

86. Antileprosydrugs
MedicationEffect
withBF
Comment
DapsoneSafeMothercan
continueBF
RifampicinSafeMothercan
continueBF

87. NACORecommendations
Whenthechildissixmonthsor
earlier,breast-feedingshould
bestoppedwithintwoweeks
whileensuringcomfortlevelof
bothmotherandinfant
Atthesametimegoodquality
complementaryfoodshouldbe
introducedensuringadequate
amountofenergy,proteinsand
micronutrients

88. ClassificationofdruguseinBF
WHO2002
1. CompatiblewithBF
2. CompatiblewithBF,monitor
infantforsideeffects
3. Avoidifpossible,monitorinfant
forsideeffects
4. Avoidifpossible,mayinhibit
lactation
5. Avoid