Use and abuse of drugs in breast feeding
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breast module by dr. kawita bapat
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Use and abuse of drugs in breast feeding
- 1. USE & ABUSE OF DRUGS IN BREAST FEEDING
- 2. Introduction • Once upon a time BF was 100% upto 12 months. now 96% BF upto 12 months,39% upto 3 months & 15% at 6 months. Daily need is 150ml/ kg/ day. • Most drugs are not of concern in BF ,also most lactating women take few drugs, also very occasionaly. • Nearly 100 yrs ago it was thought drugs given to mother rarely affect milk ,& almost never harm baby. • The PH of milk is 7.2 slighltly more acidic than maternal plasma 7.4 so it attracts organic bases like oxycodone &cafiene,so these drugs become ionised & trapped in milk. • Babies affected by these unsafe drugs get altered LFT ,reduced plateletcounts , undersedation effect leading to sudden infant death syndrome.deep pigmentation of teeth by 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 -‐ effec9ve barrier for fully developed infant • Resource limited countries – BF -‐ 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 -‐> morphine – CNS effect
- 7. RISK OF ADVERSE EFFECTS -‐ BABY • Time – feeding just before medicine is taken • Toxicity – Metronidazole / Sodium Valproate / Immuno-‐suppressants • 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
- 11. Oxytocin reflex S0mulated by • Thinks lovingly of baby • Sound of the baby • Sight of the baby • Confidence Inhibited by Worry Stress Pain Doubt
- 12. Prolactin Reflex Enhanced by:- • How early the baby is put to the breast • How often & how long baby feeds at breast • How well the baby is attached to the breast inhibited by :- • Delayed initiation of breastfeeds • Prelacteal feeds • Making the baby wait for feeds • Dummies, pacifiers, bottles • Certain medication given to mothers • Painful breast 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 -‐ 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 -‐ compa9ble
- 14. THINGS TO REMEMBER • Most drugs pass into human milk • Pass into bloodstream before they appear in milk • Medica9on appears -‐ very small amounts ( < 1% of Maternal dose) • Very few drugs -‐ 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 -‐ 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 -‐ support – posi9on – latch on -‐ • Alterna9ve medicines ?
- 17. GALACTOGOGUES • Block Dopamine receptors – Increases Prolac9n levels – Breast milk flow • Domperidone -‐ Dose 10 mg three 9mes a day – increases milk produc9on by 45 % aier 7 days of usage • Metoclopramide – 10 mg tablet -‐ some chances of extrapyramidal symptoms – tremors, bradykinesia, dystonic reac9on – depression • Needs to be gradually weaned off during weeks / months • Natural -‐ 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 -‐
- 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 -‐ 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
- 30. ANTI EPILEPTIC DRUGS • AED – An9 Epilep9c drugs / anxioly9cs – diazepam • Safe AEDs – Carbamazepine / Valproic Acid / Phenytoin – Phenobarbital n Primidone • Aken9on on Infant Monitoring -‐ 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 -‐ 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 -‐ drowsiness / weakness in baby – decreased milk produc9on • Occasional drink (glass of wine – beer) with dinner -‐ fine • Nico9ne most addic9ve – infant absorbs more nico9ne – passive smoke than breast milk – high respiratory -‐ ear infec9on n colic -‐ 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 -‐ use of decaf products in sensi9ve babies • Amphetamine – ADHD or Narcolepsy – usually compa9ble – If abused – causes irritability n sleeplessness • Recrea9onal drugs (cocaine-‐heroin-‐ PCP angel dust-‐LSD) – 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 -‐ considered • Influenza vaccine – standard injectable form (inac9vated / killed) given • MMR vaccine • HPV – Hepa99s A & B
- 37. DRUGS – CONTRA INDICATED Drug Comment Amiodarone Long half-‐life, iodine-‐containing 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 es of drugs contraindicated in breastfeeding
- 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 -‐ safe
- 41. This baby says…
- 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 -‐ immunological – emo9onal – economical – social benefit • Almost ALWAYS possible for mother to con9nue NURSING – even in rare cases where temporary weaning is necessary