Medications and the Breastfeeding Mother
Janell E. Robisch
Lorton VA USA
From: NEW BEGINNINGS, Vol. 20 No. 6, November-December 2003, pp. 204
When Trish Kuper suffered
a sudden hearing loss with a severe ear infection, the physician she
saw in Oklahoma City, Oklahoma, USA, recommended she take the steroid
drug prednisone for the next month.
He also recommended she wean
her nine-month-old daughter. When she expressed her distress over the
idea, the doctor, who was an ear, nose, and throat specialist, said
she also had the option of pumping and discarding her milk for the time
she was on the drug. "I told him that was an impossibility,"
she said.
As happened with Trish, breastfeeding
mothers often are advised to wean by doctors or other health care providers.
It's seldom necessary, according to Thomas Hale, PhD, who specializes
in studying how much medication transfers into human milk. In his book,
Medications and Mother's Milk, he writes:
Although interrupting breastfeeding
may seem safest to the physician, it is not really necessary in most
cases as the amount of drug transferred to milk is normally quite small.
It is well known that most medications have few side effects in breastfeeding
infants because the dose transferred via milk is almost always too low
to be clinically relevant or it is poorly bioavailable to the infant.
In most cases, the mother
need only talk to her doctor and consult some of the other available
resources to explore her options and find a treatment that works for
her and her baby and that does not require weaning. Most medications
are compatible with breastfeeding. When they are not, an alternative
medication or procedure is almost always available.
After her doctor recommended
that she wean, Trish Kuper went home, prescription in hand, and phoned
a friend who was a board certified lactation consultant. Her friend
read her information from Thomas Hale's book, which lists specific information
for hundreds of medications; her friend also advised her that the American
Academy of Pediatrics (AAP) had approved the use of prednisone, the
drug that she was prescribed, for nursing mothers.
When a breastfeeding mother
has a health problem that requires medication, it can be a challenging
time. Doctors commonly recommend that a mother wean her baby if she
is taking an over-the-counter or prescription medication. Mothers usually
want to continue breastfeeding and do not want to stop in order to take
medication, especially for an illness that probably won't last long,
such as a cold.
In an effort to avoid the
oftentimes remote risk of a medication having an effect on a breastfeeding
infant, mothers sometimes underestimate the risk to themselves of not
seeking treatment and doctors sometimes discount the risks of weaning.
A mother's illness may affect
not only her health and physical well-being, but also how effective
she is at mothering her children, if only temporarily. And, since breastfeeding
is more than just a feeding method, weaning a baby in order to take
medication dramatically alters the way a mother can care for and comfort
her child. According to the new edition of THE WOMANLY ART OF BREASTFEEDING,
published by La Leche League International:
Abrupt weaning is traumatic
for mother and baby. [The] mother may develop painfully engorged breasts,
risking a breast infection and compounding the problems for which she
was advised to take the medication in the first place. The mother/baby
relationship is adversely affected by sudden weaning. Caring for the
baby and keeping him content becomes difficult or impossible; the baby
is often utterly inconsolable.
As stated in THE WOMANLY
ART OF BREASTFEEDING, documented risks also exist for babies who are
not breastfeed.
A physician who advises weaning
just as a precaution may not be considering the risks associated with
feeding a baby infant formula. Formula is not the nutritional equivalent
of human milk. Babies who are formula-fed are at greater risk of illness
and allergy.
There are many things a mother
and her doctor must consider when choosing a course of treatment, including
the necessity of the medication, the compatibility of the medication
with breastfeeding, and the availability of alternative medications
or treatments. The age and health of the baby also play a role in weighing
a medication decision. Weaning should be considered only as the last
option.
Is the Medication Necessary?
The first and most obvious
question that a mother needs to ask herself and her doctor should be
whether medication is really necessary. Some mothers, who have a mild
illness such as a cold, may forego taking medication in an effort to
"protect" their baby. At the same time, since most medications
are compatible with breastfeeding, there is rarely a true need for mother
to suffer.
As the American Academy of
Pediatrics writes, "Most drugs likely to be prescribed to the nursing
mother should have no effect on milk supply or infant well being."
If, after considering all
the options, the mother and doctor decide that taking medication is
necessary, together they can explore which medication would be most
compatible with breastfeeding.
Deciding Which Drug Is Best
The drugs that are most compatible
with breastfeeding are time-tested: they have been used by nursing mothers
for a long time and have not posed significant risks. These medications
are also the least toxic to babies, have the shortest half-lives (and
are eliminated more quickly from the mother's body), and are given in
the smallest effective dose for the shortest amount of time (see sidebar
for other factors that affect the compatibility of medications with
breastfeeding). They are also drugs that pass in relatively small amounts
into the mother's milk and, thus, into her baby's system.
There are other important
points that a breastfeeding mother and her doctor should consider. First,
medications that are commonly given to babies are often good choices
for the breastfeeding mother. Also, a drug that has been used and tested
over a long period of time is likely to be better characterized with
respect to breastfeeding than one that is fairly new. If a mother is
prescribed a fairly new drug about which little is known, she may ask
her doctor about an alternative medication that has been around longer
and about which more is known.
The age and health of the
baby also affect how cautious mothers need be about a medication. Premature
infants and infants with heart defects are much more vulnerable to the
effects of medication than are healthy, full-term infants. Fortunately,
mothers are more likely to be prescribed drugs once babies are past
the newborn period. Babies who receive food other than human milk will
receive a lower dose of the medication and their higher body weight
also helps them metabolize any trace amount of medication in their mother's
milk more quickly.
Also, some medications may
not cause problems in the infant but may affect breastfeeding by reducing
the mother's milk supply, depressing the release of prolactin (the hormone
that affects milk production), or inhibiting the mother's let-down.
When Told to Wean
In some instances, a doctor
might recommend that a mother wean either while she is taking a medication
or permanently. Many factors may influence the doctor's often unnecessary
recommendation, including the baby's health and age. Other, more subjective
influences may also be at play.
Some doctors rely on biased
sources of information. Many doctors use the Physicians Desk Reference
as a source of information on various medications and their effects
on breastfeeding. The information in this publication and some other
publications, including the medical inserts provided with prescriptions,
is provided by pharmaceutical companies and is often overcautious because
of company fears of possible litigation. These companies, in order to
protect themselves from possible litigation, may state that the effects
on breastfeeding or on the breastfeeding infant are unknown or that
a mother should not nurse while taking the medication.
It is difficult for ethical
reasons to do drug research on pregnant women and breastfeeding dyads,
but frequently if that research has not been done, the Physicians
Desk Reference will state that a medication is not compatible with
breastfeeding. More objective publications include Thomas Hale's Medications
and Mother's Milk and the AAP's policy statement "The Transfer
of Drugs and Other Chemicals Into Human Milk," both of which list
a great number of medications and provide information and known research
on their safety and their possible effects on both nursing babies and
lactation itself.
Hale's book analyzes how
much medication could possibly be transferred into human milk by looking
at things like the molecular size of the chemicals in the medication
and testing the content of the milk of mothers who have taken certain
medication. When a very small perecentage of a drug's dose transfers
into milk, it is less likely to affect even a young infant.
When little or no information
is available about a fairly new drug, the mother may want to ask the
doctor if there is a suitable alternative about which there is more
information. Because most medications are compatible with breastfeeding,
a little research may be the simple answer to what seems like a complicated
problem. A mother might also point out the health and emotional risks
to her and her baby that could arise from premature weaning.
Suzie Mattern of Woodbridge,
Virginia, USA, was told that she would have to wean her exclusively
breastfed baby for 36 hours for an x-ray procedure to confirm the position
and number of the kidney stones that she had developed."I anxiously
explained to the doctor that my daughter was exclusively breastfed and
I was unable to pump enough milk in the next two days before the procedure
and that this was not a possibility."
After consulting with a La
Leche League Leader about possible alternatives and again with the doctor's
office, she discovered that there was, indeed, an alternative and safer
procedure that would not require her to interrupt breastfeeding. Suzie's
willingness to question her doctor's decision and to research the procedure
and talk further with her doctor saved her and her baby from a possibly
traumatic 36-hour weaning.
A mother, with the help of
her doctor and her baby's doctor, might also decide to take a medication
about which little is known but closely monitor her baby for untoward
side effects. In this way, the mother's medical needs are met while
she is still watching out for the well-being of her child.
Some doctors believe that
a mother should not take any medication while she is nursing and that
she should wean her baby if she wishes or needs to take it. In this
instance, a mother may want to seek a second opinion.In any case, mothers
should always try to communicate openly with their doctors, let them
know that they are breastfeeding and wish to continue to do so, and
express their wish to take a medication that would pose the least risk
to the baby and that would not require weaning (see sidebar).
As Angela Herrera writes
in her article, "A Mother With Lupus," which was published
in New Beginnings, "Don't assume your doctor will not listen. Physicians
just may not know very much about taking medications while nursing a
baby." She also writes that her exploration to find a course of
treatment for her lupus that was compatible with breastfeeding was "also
an informative experience for my doctors. I found they were eager to
know more about breastfeeding and drugs in human milk."
When Weaning Is Necessary
Unfortunately, there are
some medications, including those that contain radioactive compounds,
that pose a higher risk to the breastfeeding baby than weaning does.
Once a mother has explored all of her options and all of the possible
alternatives and has come up empty, temporary or permanent weaning might
be necessary, although fortunately this is rarely the case.
If the mother wishes and
is able to continue breastfeeding after discontinuing such a medication,
she can contact her local La Leche League Leader for information on
how to express her milk and keep up her supply while she taking the
medication. Leaders can also provide information on how to ease the
stresses of both temporary and permanent weaning.
Being Informed
In the case of medications
and mother's milk, the best thing that a mother can do is arm herself
with information with which she can approach her doctor and discuss
her alternatives in an educated and effective manner. There are many
sources of information available on specific drugs.
One mother weaned her first
son after being prescribed several medications in turn when she was
diagnosed with postpartum depression and sleep deprivation. However,
when her second son was born, she was armed with much more information
(and confidence):
I was determined to bond
well with my baby and nurse him until he decided to wean . . . . I had
difficulty with pain control after the cesarean, but understood that
I needed to take the pain medications in order to relax so we could
nurse well," Christy Murrell of Centreville, Virgina, USA, says.
"I had read enough to know that very few medications are truly
contraindicated with breastfeeding, and I chose to take the medications
the doctor prescribed . . . . These medications seemed to have no effect
on William.
Sources in the Community
LLL Leaders are a wonderful
source of information and support. LLL Leaders are not medical professionals
and do not give medical advice; however, they have access to some of
the resources listed below and may be able to provide mothers with published
information on the drug being considered. Leaders are available over
the phone and online through LLL's Help Forms. Local Groups (and their
Leaders) can be located through LLL's Web site at www.llli.org/WebIndex.html.
Sometimes, the opinion of
another medical professional can be of great use. A pediatrician who
specializes in the health of babies and children or a pharmacist may
have more up-to-date information on the effects of medication on babies
than the prescribing doctor, especially if the prescribing doctor does
not generally see infants.
When making the decision
whether or not to take medication while breastfeeding, a mother is justified
in searching for information and questioning authority. After all, mother's
milk is essential for the baby, and breastfeeding is important to both
mother and baby. The mother should be able to take care of herself and
her own needs while still providing her baby with the best possible
start. Fortunately, in most cases, this is no problem.
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Compatibility Factors
There are many factors
that affect the possible risks of maternal medication for the
baby, including the relative infant dose (how much of the medication
passes into the mother's milk through her bloodstream). Fortunately,
this dose is usually very small. Other factors include:
- The age and health
of the baby and whether the baby was premature or full-term. Because
the digestive and renal systems of premature babies may be less
well developed, they might not be able to handle the same drug
that a full-term infant of the same age could. Also, a newborn
baby might not be able to effectively process the same medication
that a nine- or 12-month-old baby could.
- When the mother
takes the medication. With a baby who breastfeeds on a fairly
regular schedule, the mother might be able to schedule her medication
at certain times to avoid breastfeeding at the time when the concentration
of the drug peaks in her bloodstream (the "peak") and
minimize the amount of medication that the baby receives through
her milk.
- How long the mother
takes the medication. A medication that has few short-term effects
may pose a risk if it is ingested over a long period of time and
builds up in the baby's system.
- Whether the baby
is exclusively breastfeeding or is receiving other types of nourishment.
If a baby is eating solids or if breastfeeding is supplemented
with formula, the baby will generally receive a smaller overall
amount of the medication, which reduces the risk to the infant.
- How well the baby's
system can process and eliminate the drug.
- How the drug is
administered. Intravenous medications generally enter the mother's
milk faster, whereas oral and topical medications take longer
to reach the mother's milk. Reference?
- Chemical characteristics
of the medication that affect its concentration in the mother's
milk. Heather McCutcheon of Calgary, Alberta, Canada, was happy
to learn that a drug that her doctor had described as "the
most breastfeeding-friendly medication" for postpartum depression
did not pass into mother's milk in great quantities: "The
studies I found online said that 2 to 100 ng/mL of the medication
would end up in my milk-a very small amount-and none was found
in the blood samples of babies whose mothers took the drug."
- Whether the drug
is short-acting or long-acting. A short-acting medication is usually
preferable because both mother and baby can eliminate the drug
from their systems more quickly.
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Creating
an Open Dialogue and
Having an Effective Relationship with Your Doctor
A mother's relationship
with her doctor will be enhanced when she can express her feelings
and her goals to her doctor. A mother may very well find it a
bit intimidating to be in conflict with her doctor or to challenge
his knowledge. If you are not comfortable with a treatment or
medication that your doctor has recommended, THE BREASTFEEDING ANSWER BOOK suggests using "tact, honesty, respect, knowledge,
and patience." Some other tips that might help you prepare
and converse with your doctor about medications include:
- Practice your response
with someone you are comfortable with before talking with your
doctor.
- Bring your partner
or a supportive friend or family member with you when you converse
with your doctor.
- Be self-confident.
Write down your questions or information in advance, and be friendly
and willing to consider alternatives.
- Foster a friendly
atmosphere with positive statements, such as "I prefer that
my baby continue to breastfeed" rather than "I refuse
to wean my baby."
- Repeat yourself
quietly and calmly at each opportunity when disagreements arise.
This can be an effective technique for making your desires clear.
- Remember and emphasize
to the doctor that the baby's parents (you) are ultimately responsible
for your baby's health.
- Seek a second opinion
if you feel that after your discussions, your doctor is not as
supportive as you would like him to be.
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References
Mohrbacher, N. & Stock,
J. THE BREASTFEEDING ANSWER BOOK. Schaumburg, Illinois: La Leche League
International, 2003.
Hale, T. Medications and
Mother's Milk, 2002. Amarillo, Texas: Pharmasoft, 2002.
Herrera, A. A mother with
lupus. New Beginnings 2001; 17(5)167.
WHEN A NURSING MOTHER GETS
SICK . Schaumburg, Illinois: La Leche League International, 1996; 4-5.
THE WOMANLY ART OF BREASTFEEDING.
Schaumburg, Illinois: La Leche League International, 2003.
Other Resources
American Academy of Pediatrics
Committee on Drugs. The transfer of drugs and other chemicals into human
milk. Pediatrics 2001; 108(3)776-789.
Briggs, B., Freeman, R. &
Yaffe, S. Drugs in Pregnancy and Lactation. Baltimore, Maryland:
Lippincott, Williams & Wilkins, 1998.
Ito, S. Drug therapy for
breastfeeding women. The New England Journal of Medicine 2000;
343(2).
Klasco, R. K., Ed. USP DI(r).
Vol. I. Drug Information for the Healthcare Professional. Greenwood
Village, Colorado: Micromedex, 2003.
Lawrence, R. and Lawrence,
R. M. Breastfeeding: A Guide for the Medical Profession. St.
Louis, Missouri: Mosby, 1999; 351-393.
Last updated 11/17/06 by jlm.
Page last edited Sun Oct 14 09:29:43 UTC 2007.
