TAKING MEDICATIONS SAFELY WHILE BREASTFEEDING

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TAKING MEDICATIONS SAFELY WHILE BREASTFEEDING

Most drugs that go into your body will also go into your milk, so before you take any medication, you need to consider how it will affect your baby and whether or not it has any effects on lactation. While most medications are safe to take while breastfeeding, it's wise to talk to your doctor or your baby's doctor before taking anything. Here are some general guidelines.

There are three issues to consider when considering taking medication while breastfeeding:

Do you need the drug?
Will the drug affect baby?
Will the drug affect your ability to make milk?

Answering these questions should help you weigh the risks and the benefits of taking a particular medication. As you gather information about the medication, you may also want to consider whether timing the dosage can minimize baby's exposure to the drug. If it's absolutely necessary to avoid breastfeeding while taking a medication, consider temporary weaning pump and dump as an alternative to stopping breastfeeding entirely.

Do you need the drug? How sick are you? Be honest. Trying to tough it out for several days may actually decrease your milk supply, and you may not be a very good mother to your baby during this time. Taking medicine may often lessen the severity and duration of your illness, and in some situations, it's absolutely necessary. If the medication is necessary for your own well-being, usually the benefits to you--and indirectly, to baby--will outweigh the risks of baby being exposed to a small amount of the medication in your milk. (There are exceptions to this. See the drug chart for information on medications that should not be taken by breastfeeding mothers.)

On the other hand, if you have a minor ailment, such as a cold, consider alternatives to taking medicine. While nearly all over-the-counter cold remedies are safe to take while breastfeeding, many are only marginally effective. You may get more relief by treating your cold the old- fashioned way: steam, extra fluids, rest, and a tincture of time.

Another question to ask is do you need this drug? Often, if a particular drug is not safe to take while breastfeeding, or if little information is available about a drug, you and your physician may decide to treat your condition with another medication that is known to be safe. If there are several different drugs that can be used to treat your illness effectively, the doctor should choose the one least likely to affect your baby and your milk production. This may mean using older drugs rather than the latest thing from the pharmaceutical company.

If your doctor thinks it is necessary for you to wean because of a drug or a particular medical procedure, ask do you need this drug now? Perhaps you can safely delay the treatment until your baby is older or weaned. Drugs in breastmilk present less of a problem to an older breastfed baby. Yet if you're planning to nurse until your baby weans herself, the day when you will no longer be breastfeeding may be a lot further off than either you or your doctor anticipate.

Will the drug affect baby?

Many drugs taken by a mother make their way into her milk. The important question is not whether the drug gets into milk, but whether the levels in the milk are such that they will affect the baby.

Here are some of the factors that influence how much of a drug gets into a mother's milk and how it affects her baby.

While most drugs do pass into your milk, most appear in only minute amounts - usually around one percent or less of the amount taken by the mother.
The route of administration influences how fast the medication enters and clears from your blood, and therefore your milk. For example, some medications come in both oral and inhalant forms, which have different clearing times.
It's better to use a short-acting medicine that is taken three or four times a day than to use a long-acting, once-a-day form of the medication. . Although less convenient, short-acting medications clear from your blood and milk faster. They're also easier for babies to metabolize, so there is less risk of the drug accumulating in the infant's system.
Consider the age of your baby. More caution is called for when giving medication to a mother who is breastfeeding a premature or newborn infant ten times a day than when prescribing medication for a woman breastfeeding a one-year-old four times a day. An infant that feeds more frequently naturally gets more of the medicine, and the smaller size of the younger infant means the drug will be more concentrated in the baby's body. . Also, the liver and the kidneys of older infants are better able to metabolize and eliminate the drug.
Most drugs taken by the mother are of less concern while breastfeeding than if she were taking them during pregnancy. If a drug is safe to use during pregnancy, it is probably safe during lactation. There is more reason to be concerned about the effects of a drug on a growing fetus than on a fully developed infant.
If there are concerns about possible effects on your baby, can the doctor monitor the baby during the time you are taking the drug? This might involve checking levels of the drug in your milk or the baby's blood, or watching carefully for changes in your baby's behavior.
Be particularly cautious about taking more than one drug while breastfeeding. While each drug taken separately may be listed in the safe category, together they may be unsafe (if not for your baby, for you). Be sure to tell your doctor about any medications you are already taking before he prescribes another. Pharmacists are often the most reliable source of information on drug interactions.

Will the drug affect your ability to make milk?

Some drugs do not harm the baby, but may affect your milk volume by suppressing the milk-making hormones. On the other hand, some conditions (i.e., hypothyroidism) can interfere with your ability to make milk, and medications to treat the problem will improve milk production.

Weighing the risks

When considering the risks of taking a particular medication while breastfeeding, it's important to understand the nature of these risks, along with the risks of weaning.

A physician will recommend weaning when uncertain about the effects of a drug in human milk. The when in doubt leave it out policy is common among healthcare providers, since it's impossible to keep up with all the research on the safety of drugs while breastfeeding. Yet this approach assumes that there are no risks involved in weaning to formula. While many physicians, like the general public, make this assumption, it is not true. The risks of exposing a baby to a drug in breastmilk should be weighed against the known risks of exposing a baby to infant formula while depriving him of breastmilk. Remember that all the advantages of breastfeeding (see "Breastfeeding Benefits from Top to Bottom" and "Comparison of human milk and infant formula") can be turned around and understood as risks of formula feeding.
Be aware that often what a mother is told about taking a medication about breastfeeding is based more on legal considerations than scientific knowledge. The information available from pharmaceutical companies about a drug, either in package inserts or in The Physician's Desk Reference (the PDR), often advises mothers not to breastfeed while taking a drug, but this advice reflects the company's desire to protect itself from lawsuits and to avoid having to do expensive research that would allow it to say a certain drug is safe. Healthcare providers advising nursing mothers should rely on additional sources of information that are more accurate and breastfeeding-friendly. This would prevent babies from being weaned unnecessarily.

Taking medication safely

Once you and your doctor have weighed the alternatives and together made the decision that it is in the best interests of you and your baby to take the medicine, be sure you understand the dosage, the timing, the possible adverse effects on you (e.g., stomach ache, headache, diarrhea), and if there are any possible adverse effects to watch for in your baby.

When you pick up the medicine at the pharmacy, check the label and be sure it agrees with what your doctor told you. Keep in mind that doctors oftentimes do not discuss possible adverse drug reactions with patients for two reasons: they occur in a small minority of patients, and if you expect certain reactions, you are more likely to experience them, or imagine you do.

Timing the dosage

Ask your doctor or pharmacist for any information about the medicine that would help you time the dosage and the baby's feedings to get the most medicine into you, but the least into your milk.

If the medication is one that should be used with caution, it may help to take the medication right after feeding your baby. Most milk is freshly made during the feeding and the breast stores only a small quantity. While baby is feeding, the blood flow to the breasts and, therefore, the potential delivery of the drug to your milk is highest. It decreases after the feed.
Most drugs reach their maximum concentration in the breastmilk 1-2 hours after being taken. So, taking medication right after you feed allows much of the medicine to be cleared from your milk before the next feeding.
Best to take once-a-day medications just before your baby's longest feeding interval (usually right after putting your baby to sleep at night), unless the side effects of the medication could keep you and/or your baby awake. With once-a-day medication, when you take the medicine has less effect on the concentration of the drug in breastmilk than with medications taken 3-4 times a day.
While timing your dosage may help to minimize your baby's exposure to the drug in your milk, don't make yourself and your baby crazy trying to delay or schedule feedings. If you have a baby who nurses frequently throughout the day and night, you will probably both be calmer and better off if you take the medicine as directed and nurse your baby on cue.

Pump and dump

Some drugs (e.g., radioactive substances used in x-ray diagnostic procedures) require temporary weaning. If your doctor advises that you wait to nurse your baby until a potentially harmful drug is out of your system, pump your milk every 3-4 hours during the time you are not nursing and discard the milk. Meanwhile, use the "safe" milk you previously stored in the "milk bank" in your freezer.

INFORMATION ON SPECIFIC DRUGS

The tables on this page list medications in three categories:

Common medications that are safe to use while breastfeeding
Drugs that require careful monitoring by a physician when taken while breastfeeding
Drugs that should not be used while breastfeeding.

Talking with your health professional about any medication you take is very important, and a nursing mother should always remind her physician that she is breastfeeding when decisions are being made about medications.

If you need additional information about a medication, or if you need information about a medication not listed in these tables, please consult additional sources of information.

Common medications that are safe to use while breastfeeding

The safety of the following medications is established for short-term use only. If you are required to take one of these for more than one or two weeks, consult a physician.

acetaminophen	asthma medications (cromolyn, inhalant bronchodilators)	Kaopectate
acyclovir	barium	laxatives
anesthetics local (e.g., dental work)	chloroquine (antimalarial)	muscle relaxants
antacids	cortisone	pinworm medications
antibiotics (tetracycline* and sulfa**)	decongestants	propranolol
anticoagulants	digitalis	propylthiouracil
anticonvulsants	diuretics	silicone from implants
antihistamines	ibuprofen	thyroid medications
aspartame	insulin	vaccines
		vitamins
* Avoid taking tetracycline for longer than ten days ** Avoid in newborn period

Drugs that require careful monitoring by a physician when taken while breastfeeding

Whether these drugs and medications are safe to take while breastfeeding depends on many factors: the dosage, age of infant, duration of therapy, and timing of dosage and breastfeeding. Consult a physician knowledgeable about drugs during breastfeeding if you need to take any of the following medications long-term.

alcohol	general anesthetics*	morphine
antidepressants	indomethacin	oral contraceptives
aspirin	isoniazid	Paxil
codeine	lithium**	phenobarbitol
Demerol	metoclopramide	Prozac
ergots	metronidazole (Flagyl)***	Valium
		Zoloft
* It is safe to breastfeed six to twelve hours after most general anesthetics. Some authorities consider lithium absolutely contraindicated while breastfeeding; others believe lithium can be used cautiously, as long as blood lithium concentration in the baby is monitored. * Authorities recommend giving the mother a single two-gram dose and having her discontinue breastfeeding for only twelve to twenty-four hours.

Drugs that should not be used while breastfeeding

amphetamines	heroin	Mysoline
antimetabolite drugs (anti-cancer drugs)	Lindane	nicotine
cocaine	marijuana	Parlodel
cyclosporine	methotrexate	PCP
		radioactive drugs for diagnostic tests*
* May need to stop breastfeeding temporarily. Consult a nuclear medicine specialist.

SOURCES OF INFORMATION ON DRUGS IN HUMAN MILK

If you need more information about taking a specific medication during breastfeeding, consult the following sources. Or ask your doctor to find out more about the drug using these references.

American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics 1994; 93:137-50. Reprinted in The Breastfeeding Answer Book, rev. ed. by N. Mohrbacher and J. Stock. Schaumburg, IL: La Leche League International, 1997, 525- 538. (Most La Leche League Leaders have access to this book and will read the information about a specific drug to you over the phone.)

Briggs, G., Freeman, R., and Yaffe, S. Drugs in Pregnancy and Lactation, 4th ed. Baltimore: Williams and Wilkings, 1994.

Hale, T. Medications and Mother's Milk, 7th ed. Amarillo, TX: Pharmasoft, 1998-99. (Order from LLLI, or see Dr. Hale's website at http://neonatal.ttuhsc.edu/lact/index.html)

Lawrence, R. Breastfeeding: A Guide for the Medical Profession, 5th ed. St. Louis: Mosby, 1999.

US Pharmacopeial Convention. United States Pharmacoepia Dispensing Information: Drug Information for the Health Care Professional, 16th ed. Rockville, Maryland: US Pharmacopeial Convention, 1996.

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