breast feeding

1. USE$&$ABUSE$OF$DRUGS$IN$
BREAST$FEEDING$
$$$$$$$$$

2. Introduction
• OnceuponatimeBFwas100%upto12months.now96%
BFupto12months,39%upto3months&15%at6months.
Dailyneedis150ml/kg/day.
• MostdrugsarenotofconcerninBF,alsomostlactating
womentakefewdrugs,alsoveryoccasionaly.
• Nearly100yrsagoitwasthoughtdrugsgiventomotherrarely
affectmilk,&almostneverharmbaby.
• ThePHofmilkis7.2slighltlymoreacidicthanmaternal
plasma7.4soitattractsorganicbaseslikeoxycodone
&cafiene,sothesedrugsbecomeionised&trappedinmilk.
• Babiesaffectedbytheseunsafedrugsgetaltered
LFT,reducedplateletcounts,undersedationeffectleadingto
suddeninfantdeathsyndrome.deeppigmentationofteethby
tetracyclines.

3. INTRODUCTION$
• Commonly'used'drugs'–'rela0vely'safe'
• Dose'received'via'milk'–'much'small'–'than'safe'
dose'directly'given'
• Most'drugs'–'not'of'concern'in'BF'
• Most'lacta0ng'mothers'take'very'few'medicines'
–'very'occasionally'
• Not'advisable'to'suspend'BF'0ll'–'mother’s'
medica0on''

4. CURRENT$SCENARIO''
• No$of$medica9ons$available$–$many$
• Ongoing$medica9on$–$very$few$require$
–$cessa9on$of$BF$–$vigilance$required$
(infant$vulnerable)$
• Difference$–$placenta$lets$drug$enter$–$
to$cross$developing$fetus’s$blood$
stream$–$Breast$serves$L$effec9ve$
barrier$for$fully$developed$infant$
• Resource$limited$countries$–$BF$L$
cornerstone$of$infant$survival$$

5. USE$OF$DRUGS$
• Factors$affec9ng$concentra9on$of$
Drugs$in$Breast$milk$?$
• Influences$the$Risk$of$adverse$effects$
on$Baby$?$
• Factors$determining$transfer$of$drugs$
in$Breast$milk$?$$$

6. FACTORS$–$CONCENTRATION$IN$MILK$
• Plasma$concentra9on$–$passive$diffusion$–$
drug$distribu9on$in$various$9ssues$$
• Plasma$protein$binding$–$unbound$drugs$–$
diffuse$readily$
• Size$of$molecule$
• Ioniza9on$–$cross$membrane$in$un$ionized$
form$
• Lipid$solubility$–$fat$droplets$of$milk$
• $Maternal$pharmacogenomics$–$eg.$codeine$
L>$morphine$–$CNS$effect$$$

7. RISK$OF$ADVERSE$EFFECTS$L$BABY$
• Time$–$feeding$just$before$medicine$is$
taken$
• Toxicity$–$Metronidazole$/$Sodium$
Valproate$/$ImmunoLsuppressants$
• Oral$bioavailability$
• Volume$of$breast$milk$
• Infant$dose$
• Age$of$infant$–$Preterm$babies$(immature$
kidneys$/$liver)$–$very$ill$babies$
(compromised$immune$system)$

8. FACTORS$DETERMINING$TRANSFER$$
• Milk$–$composi9on$–$lipid$/$protein$
concentra9on$
• Mother$–$renal$/$hepa9c$excre9on$/$dose$n$
dura9on$of$therapy$/$route$of$administra9on$
• Infant$–$age$/$drug$absorp9on$/$hepa9c$–$
renal$excre9on$/$volume$/$safety$
• Drug$–$solubility$/$molecule$size$/$oral$
bioavailability$/$toxicity$/$suppressive$effect$/$
long$or$short$ac9ng$$$$
$

10. LOVELATCH&
LIVE

11. Oxytocinreflex
S0mulated'by'
• Thinks'lovingly'of'
baby''
• Sound'of'the'baby''
• Sight'of'the'baby''
• Confidence''
Inhibited'by'
'
Worry''
Stress''
Pain''
Doubt'''

12. ProlactinReflex
Enhancedby:-
• Howearlythebaby
isputtothebreast
• Howoften&how
longbabyfeedsat
breast
• Howwellthebaby
isattachedtothe
breast
inhibitedby:-
• Delayedinitiationof
breastfeeds
• Prelactealfeeds
• Makingthebabywait
forfeeds
• Dummies,pacifiers,
bottles
• Certainmedication
giventomothers
• Painfulbreast
conditions

13. AAP$–$AMERICAN$ACADEMY$OF$PEDIATRICS$
• NEW$DRUG$CLASSIFICATION$
• Cytotoxic$Drugs$–$cyclophosphamide,$cyclosporine,$
methotrexate,$doxorubicin,$amphetamine$
• Drugs$of$Abuse$–$cocaine,$heroine,$marijuana$
• Radioac9ve$Compounds$$L$Copper$/$Iodine$$$
• Drugs$–$Unknown$effects$but$of$concern$–$an9anxiety,$
an9$depressants,$an9$psycho9c,$metronidazole,$
metoclopramide,$chloramphenicol$$
• Drugs$–$significant$effect$–$to$be$given$with$cau9on$–$
atenolol,$bromocrip9ne,$aspirin,$ergotamine,$lithium,$
phenindione,$phenobarbital,$acebutolol,$primidone$$
• Compa9ble$with$BF$–$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Silicone$implants$L$compa9ble$

14. THINGS$TO$REMEMBER$
• Most$drugs$pass$into$human$milk$
• Pass$into$bloodstream$before$they$appear$in$milk$
• Medica9on$appears$L$very$small$amounts$($<$1%$of$
Maternal$dose)$$
• Very$few$drugs$L$contraindicated$for$nursing$mothers$
• A$commonly$prescribed$drug$for$infant$–$safe$
• Drugs$safe$during$pregnancy$–$safe$in$BF$
• Not$absorbed$by$GI$tract$–$safe$–$eg$Inj$Heparin,$
Insulin,$LA$n$Local$creams$$$$

15. CASE$1$
• Primi$with$FTND$–$Healthy$child$3$kg.$$
• PP$Day$3$–$Breast$milk$flow$less$–$baby$
hungry$/$crying$–$top$feeds$given$–$baby$
comfortable$
• No$retracted$/$cracked$nipples$L$not$
comfortable$with$milk$flow$
• Advice$–$Medica9ons$$

16. DRUGS$–$STIMULATE$BREAST$MILK$
• Domperidone$–$Metoclopramide$–$
galactogogues$–$high$level$of$efficacy$??$
• Concerns$–$over$usage$–$9me$period$?$$
• Non$pharmacological$methods$–$more$
frequent$BF$–$correct$advice$L$support$–$
posi9on$–$latch$on$L$$$$
• Alterna9ve$medicines$?$$

17. GALACTOGOGUES$
• Block$Dopamine$receptors$–$Increases$
Prolac9n$levels$–$Breast$milk$flow$
• Domperidone$L$Dose$10$mg$three$9mes$a$day$–$
increases$milk$produc9on$by$45$%$aier$7$days$
of$usage$
• Metoclopramide$–$10$mg$tablet$L$some$chances$
of$extrapyramidal$symptoms$–$tremors,$
bradykinesia,$dystonic$reac9on$–$depression$$
• Needs$to$be$gradually$weaned$off$during$
weeks$/$months$
• Natural$L$fenugreek,$herbal$teas,$coconut$milk$
–$dry$coconut$

18. CRACKED$NIPPLES$
• Advice$–$Lanolin$cream,$emollient,$cocoa$
buker$
• Any$S$/$E$–$if$it$goes$in$baby’s$mouth$
$$$$

19. CASE$2$
• On$14$th$PP$day,$pa9ent$c/o$swelling$/$redness$over$
Right$breast$in$upper$&$lateral$quadrant$–$last$2$
days.$Feverish$feel,$pain$in$right$breast$that$increases$
during$feeding$
• No$relief$with$home$treatment$
• C$/$E$–$Breast$lump$of$4$cm$dimension$in$upper$/$
outer$quadrant$–$tender$with$redness$–$Rest$of$
breast$examina9ons$–$Normal$/$No$$axillary$LN$
palpable$$
• USG$breasts$advised$–$confirms$presence$of$Breast$
abscess$
• Management$??$$$$

21. • An9bio9cs$??$–$Ampicillin$–$Amoxycillin$–$
Clavulanate$Cephalosporins$
• An9$inflammatory$drugs$?$–$Diclofenac$/$
Paracetamol$/$Trypsin$/$Bromelain$/$
Serra9opep9dase$
• Dura9on$–$can$she$breast$feed$from$affected$
side$?$
• No$relief$aier$5$days$$
• Surgical$therapy$–$I$&$D$(USG$guided$–$open)$
• Con9nua9on$of$medica9on$–$2$weeks$more$$

22. POST$PARTUM$PYREXIA$
• D$/$D$
• Lower$UTI$–$An9bio9cs$/$$urinary$
an9spasmodics$/$alkalizers$
• Malarial$Fever$–$Medica9ons$?$–$Time$dura9on$?$
• An9$malarial$drugs$–$safe$($Chloroquine,$
primaquine,$artesunate,$quinine$)$$Doxycycline,$
clindamycin$–$short$dura9on$$$
• Infant$s9ll$needs$–$own$an9$malarial$medicines$
• Diarrhoea$–$$
• Fungal$infec9on$L$$

23. CASE$3''
• Primi$with$spontaneous$concep9on$with$c$
sec9on$delivery$at$39$weeks$of$gesta9on,$4$
weeks$ago$–$Unevenoul$
• Working$mother$needs$Contracep9ve$advice$–$
at$least$for$next$3$years$
• No$posi9ve$past$history$
• Wishes$to$con9nue$BF$9ll$6$months$–$Not$keen$
on$IUD$/$Barrier$method$$

24. CONTRACEPTION$
• LAM$–$Lacta9on$Amenorrhea$Method$
• Progesterone$only$pills$–$Desogestrel$0.075$mg$
• Inj$Depoprovera$$
• COCs$aier$stopping$of$BF$
• LNG$IUD$
• Estrogen$–$suppresses$milk$produc9on$

25. PP$DEPRESSION$

26. PP$DEPRESSION$
• Many$nursing$mothers$experience$‘PP$Blues’$/$
clinical$depression$
• Beker$to$Rx$depression$while$con9nuing$BF$(+ve$
effect$–$neurodevelopment)$
• With$medica9ons$–$mothers$able$to$manage$
beker$
• SSRIs$(Serotonin$Specific$Receptor$Inhibitors)$–$
Tricyclic$An9$Depressants$(TCAs)$–$Mood$
Stabilizers$like$Valproic$acid$–$safe$(very$small$
amt$in$Breast$Milk)$
• Wellbutrin$–$older$an9depressant$–$safe$(v$small$
amount$in$Br$Milk)$

27. SPECIAL$CASES$
• Known$Asthama9c$–$On$treatment$
• An9$Koch’s$Rx$
• Epilep9c$–$On$Rx$
• MVR$–$On$An9$coagulants$$
• Known$HT$–$On$Rx$
• Pep9c$Ulcer$–$Antacids$
• HIV$posi9ve$mother$on$medica9on$
'''''

28. ANTI$ASTHAMATIC$L$ANTI$
KOCH’S''
• Asthma$–$inhaled$drugs$safe$–$systema9c$absorp9on$much$
less$
• Short$ac9ng$Beta$agonists$–$used$at$usual$dose$–$unlikely$to$
be$transferred$$
• Steroids$–$Prednisolone$up$to$80$mg$–$can$be$safe$–$to$
withhold$feeds$for$4$hours$$aier$each$dose$
• Most$An9$Koch’s$drugs$–$safe$$
• Currently$Isoniazid,$Rifampicin,$Ethambutol,$Streptomycin$
(First$line)$n$Kanamycin$n$Cycloserine$(second$line)$–$
considered$by$AAP$–$compa9ble$with$BF$$$
• No$clear$data$on$Pyrazinamide,$Ethinamide$n$Capreomycin$
–$safety$
• Beker$to$examine$infants$for$signs$n$symptoms$of$toxicity$$$$$

29. ANTI$EPILEPTIC$DRUGS$

30. ANTI$EPILEPTIC$DRUGS$
• AED$–$An9$Epilep9c$drugs$/$anxioly9cs$–$
diazepam$
• Safe$AEDs$–$Carbamazepine$/$Valproic$
Acid$/$Phenytoin$–$Phenobarbital$n$$
Primidone$$$
• Aken9on$on$Infant$Monitoring$$L$
drowsiness,$difficulty$in$sucking,$no$weight$
gain,$breathing$problems,$altered$sleep$
pakern,$abnormal$tone$
• Infant’s$ability$to$tolerate$drugs$decreases$

31. ANTI$COAGULANTS$–$ANTI$HT$
• Warfarin$–$safe$–$first$line$of$therapy$–$
excessive$dietary$restric9on$of$vegetables$–$
reduce$milk$flow$$
• LMWH$–$gold$standard$$
• Novel$an9coagulants$–$Apixaban$–$very$safe$
• Digoxin$–$safe$
• Most$An9$HT$taken$during$pregnancy$–$safe$$
• Ace$inhibitors$–$if$needed$–$Enalapril$/$
Captopril$–$safe$$
• Preterm$infants$–$watch$for$hypotension$$
• $$$$$Avoid$Diure9cs$$

32. SPECIAL$CASES$
• Drugs$–$disorders$of$Gastric$acid$/$ulcera9ons$
–$Dyspepsia$–$Aluminium$/$Mg$/$H2$receptors$
antagonists$–$Rani9dine$/$PPI$–$Omeprazole$,$
Pantoprazole$–$Safe$
• ARV$drugs$–$($mother$–$child$)$–$significant$
benefits$L$protects$diarrhea$/$malnutri9on$/$
pneumonia$
• An9$allergic$medica9ons$–$fexo$fenadine$/$
loratadine$/$cetrizine$$$$$$

33. SOCIAL$DRUGS$
• Alcohol$–$advise$delay$9ll$aier$feed$–$wait$for$2$
hours$before$next$feed$–$<$2$%$gets$secreted$L$
drowsiness$/$weakness$in$baby$–$decreased$milk$
produc9on$
• Occasional$drink$(glass$of$wine$–$beer)$with$dinner$L$
fine$
• Nico9ne$most$addic9ve$–$infant$absorbs$more$
nico9ne$–$passive$smoke$than$breast$milk$–$high$
respiratory$L$ear$infec9on$n$colic$L$$Nico9ne$
replacement$therapy$–$preferable$to$smoking$(to$
avoid$sudden$infant$death$syndrome)$–$decreases$
milk$produc9on$
$

34. SOCIAL$DRUGS$
• High$caffeine$intake$($>$5$cups$a$day)$–$
irritability$/$poor$sleep$pakern$in$infant$$L$use$
of$decaf$products$in$sensi9ve$babies$
• Amphetamine$–$ADHD$or$Narcolepsy$–$usually$
compa9ble$–$If$abused$–$causes$irritability$n$
sleeplessness$$
• Recrea9onal$drugs$(cocaineLheroinL$PCP$angel$
dustLLSD)$–$AVOID$
• If$one$abuses$drugs$–$get$help$–$not$to$BF$
• Needs$self$control$–$some$sacrifice$
'

35. COEXISTING$MENTAL$HEALTH$
DISORDERS$
• Substance$Use$Disorder$+$Mental$Health$
Condi9ons$–$persistent$symptoms$
• Both$needs$to$be$treated$–$at$same$9me$
• Depression,$anxiety,$post$trauma9c$stress$
disorder$(PTSD)$n$ea9ng$disorder$
• More$common$following$divorce,$loss$of$child$
custody,$death$of$husband,$domes9c$violence$$
'

36. VACCINES$
• US$CDC$documents$–$neither$inac9vated$nor$
live$vaccines$given$to$BF$mother$–$affect$safety$
of$BF$for$mother$/$infant$
• Akenuated$Rubella$vaccine$–$detected$in$
Breast$milk$–$no$effect$on$infant$
• Varicella$vaccine$L$considered$
• Influenza$vaccine$–$standard$injectable$form$
(inac9vated$/$killed)$given$
• MMR$vaccine$
• HPV$–$Hepa99s$A$&$B$

37. DRUGS$–$CONTRA$INDICATED$
Drug'Comment'
Amiodarone'Long'halfIlife,'iodineIcontaining'molecule,'
and'may'affect'thyroid'func0on'in'infant'
An0neoplas0cs'Leukopenia,'bone'marrow'suppression'
Gold'salts'Rash,'nephri0s,'haematological'
abnormali0es'
Iodine'High'doses'(>150'micrograms'daily)'lead'to'
risk'of'infant'hypothyroidism'
Lithium'BreasUeeding'only'feasible'with'rigorous'
monitoring'
Radiopharmaceu0cals'Contact'obstetric'informa0on'service'
Re0noids'(oral)'Poten0al'for'serious'adverse'effects'
amplesofdrugscontraindicatedinbreastfeeding

38. CONTRA$INDICATIONS$
• Bromocrip9ne$–$Ergotamine$(migraine)$–$
Tetracycline,$Cyclosporins,$
Cyclophosphamides,$Methotrexate,$
Doxirubin$(Cancer$/$Organ$Transplant$
rejec9on)$
• Radioac9ve$substance$–$to$carry$out$test$–$
pump$enough$Breast$milk$before$test$n$
freeze$n$aier$test$–$pump$to$maintain$flow$
but$discard$milk$9ll$its$safe$$$$

39. ALTERNATIVE$
MEDICATIONS$
• Herbal$Prepara9ons$–$Not$all$are$safe$
• Herbs$–$Natural$but$can$be$quite$potent$and$
with$side$effects$
• All$prepara9on$taken$in$modera9on$L$safe$$$

41. Thisbabysays…

42. TO$CONCLUDE$
• If$drug$needed$–$prescribe$–$lowest$possible$dose$
• Temporary$suspend$BF$/$express$milk$–$poten9ally$
toxic$drugs$
• Lengthy$treatment$of$toxic$drug$–$not$possible$to$
con9nue$BF$
• Select$drug$with$rela9ve$short$half$life$
• Feed$infant$before$taking$dose$$
• Reassure$–$drug$will$return$in$blood$stream$once$
plasma$concentra9on$falls$$$

43. TAKE$HOME$MESSAGE$
• BF$–$associated$with$nutri9onal$L$
immunological$–$emo9onal$–$
economical$–$social$benefit$
• Almost$ALWAYS$possible$for$
mother$to$con9nue$NURSING$–$
even$in$rare$cases$where$
temporary$weaning$is$necessary$$$

44. $$$$$THANK$YOU$