This document provides guidance for pharmacists on medications and breastfeeding. It discusses evaluating the risks and benefits of medication use during breastfeeding using a benefit-risk analysis. It identifies resources pharmacists can use to determine if a medication is compatible with breastfeeding, such as Micromedex and LactMed. The document outlines factors that determine if and how much of a drug passes into breastmilk, such as its properties and the mother and infant's characteristics. It provides a stepwise approach pharmacists can recommend to minimize infant drug exposure through breastmilk.
This document provides guidance for pharmacists on medications and breastfeeding. It discusses evaluating the risks and benefits of medication use during breastfeeding using a benefit-risk analysis. It identifies resources pharmacists can use to determine if a medication is compatible with breastfeeding, such as Micromedex and LactMed. The document outlines factors that determine if and how much of a drug passes into breastmilk, such as its properties and the mother and infant's characteristics. It provides a stepwise approach pharmacists can recommend to minimize infant drug exposure through breastmilk.
This document provides guidance for pharmacists on medications and breastfeeding. It discusses evaluating the risks and benefits of medication use during breastfeeding using a benefit-risk analysis. It identifies resources pharmacists can use to determine if a medication is compatible with breastfeeding, such as Micromedex and LactMed. The document outlines factors that determine if and how much of a drug passes into breastmilk, such as its properties and the mother and infant's characteristics. It provides a stepwise approach pharmacists can recommend to minimize infant drug exposure through breastmilk.
This document provides guidance for pharmacists on medications and breastfeeding. It discusses evaluating the risks and benefits of medication use during breastfeeding using a benefit-risk analysis. It identifies resources pharmacists can use to determine if a medication is compatible with breastfeeding, such as Micromedex and LactMed. The document outlines factors that determine if and how much of a drug passes into breastmilk, such as its properties and the mother and infant's characteristics. It provides a stepwise approach pharmacists can recommend to minimize infant drug exposure through breastmilk.
What Dispensing Pharmacists What Dispensing Pharmacists Need To Know Need To Know Frank J . Nice, RPh, DPA, CPHP Frank J . Nice, RPh, DPA, CPHP Derwood, MD 20855 Derwood, MD 20855 fjncat@hotmail.com fjncat@hotmail.com www.nicebreastfeeding.com www.nicebreastfeeding.com gg 301 301--840 840--0270 (H) 0270 (H) 240 240--506 506--2568 (C) 2568 (C) OBJ ECTIVES OBJ ECTIVES OBJ ECTIVES OBJ ECTIVES Be able to identify the benefits and risks of Be able to identify the benefits and risks of yy medication use during breastfeeding medication use during breastfeeding Be able to identify available resources for Be able to identify available resources for di ti d i b tf di di ti d i b tf di medication use during breastfeeding medication use during breastfeeding Be able to utilize tools and techniques for Be able to utilize tools and techniques for evaluating medication use during breastfeeding evaluating medication use during breastfeeding evaluating medication use during breastfeeding evaluating medication use during breastfeeding Be able to identify adverse effects in children of Be able to identify adverse effects in children of mothers who are breastfeeding and taking mothers who are breastfeeding and taking di ti di ti medications medications Be able to counsel mothers who are Be able to counsel mothers who are breastfeeding and taking or will take medications breastfeeding and taking or will take medications 22 breastfeeding and taking or will take medications breastfeeding and taking or will take medications Photo Courtesy of NIH Photo Courtesy of NIH 33 Benefit Benefit--Risk Analysis Risk Analysis Benefit Benefit Risk Analysis Risk Analysis Benefits of breastfeeding (See Handout) + Benefits of breastfeeding (See Handout) + Benefits of breastfeeding (See Handout) + Benefits of breastfeeding (See Handout) + Benefits of the drug (from the package Benefits of the drug (from the package insert and/or literature) insert and/or literature) Versus Versus Risks of formula use or NOT breastfeeding Risks of formula use or NOT breastfeeding gg (See Handout) + Risks of the drug (from (See Handout) + Risks of the drug (from the package insert and/or literature) the package insert and/or literature) 44 SOURCES OF INFORMATION SOURCES OF INFORMATION SOURCES OF INFORMATION SOURCES OF INFORMATION Journal Articles Journal Articles Nice References Nice References Nice References Nice References AAP Committee on Drugs AAP Committee on Drugs (See Website List) (See Website List) MICROMEDEX (See Website List) MICROMEDEX (See Website List) Books Books Books Books NNonprescription Drugs for the Breastfeeding Mother, 2 onprescription Drugs for the Breastfeeding Mother, 2 nd nd Edition Edition Nice (See Slide) Nice (See Slide) Medications and Mothers Milk 15 Medications and Mothers Milk 15 th th Edition Edition Medications and Mothers Milk, 15 Medications and Mothers Milk, 15 Edition Edition Hale Hale (See Slide) (See Slide) Drugs in Pregnancy and Lactation, 9 Drugs in Pregnancy and Lactation, 9 th th Edition Edition Briggs, Freeman, and Yaffe (See Slide) Briggs, Freeman, and Yaffe (See Slide) Drugs and Human Lactation, 2 Drugs and Human Lactation, 2 nd nd Edition Edition Bennett (WHO) Bennett (WHO) 55 66 77 88 99 SOURCES OF INFORMATION SOURCES OF INFORMATION SOURCES OF INFORMATION SOURCES OF INFORMATION Pharmaceutical Companies Pharmaceutical Companies Pharmaceutical Companies Pharmaceutical Companies Websites Websites (See Next Slide) (See Next Slide) Lactation Study Center Lactation Study Center Lactation Study Center Lactation Study Center Ruth Lawrence, MD Ruth Lawrence, MD University of Rochester University of Rochester University of Rochester University of Rochester 601 Elmwood Avenue, Rochester, NY 14642 601 Elmwood Avenue, Rochester, NY 14642 (585) 275 (585) 275--0088; Mon 0088; Mon--Fri 8AM Fri 8AM--5PM 5PM (585) 275 (585) 275 0088; Mon 0088; Mon Fri, 8AM Fri, 8AM 5PM 5PM 10 10 BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES Nice Breastfeeding Nice Breastfeeding www.nicebreastfeeding.com www.nicebreastfeeding.com LactMed / TOXNET / NLM/ NIH LactMed / TOXNET / NLM/ NIH LactMed / TOXNET / NLM / NIH LactMed / TOXNET / NLM / NIH http://toxnet.nlm.nih.gov/cgi http://toxnet.nlm.nih.gov/cgi-- bi / i /ht l ?LACT bi / i /ht l ?LACT bin/sis/htmlgen?LACT bin/sis/htmlgen?LACT Thomas Hale InfantRisk Center Thomas Hale InfantRisk Center http://www.infantrisk.com/category/ http://www.infantrisk.com/category/ breastfeeding breastfeeding 11 11 breastfeeding breastfeeding BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES Breastfeeding Online Breastfeeding Online http://breastfeedingonline.com http://breastfeedingonline.com KellyMom KellyMom yy http://www.KellyMom.com http://www.KellyMom.com American Academy of Pediatrics Policy Statement: The Transfer of American Academy of Pediatrics Policy Statement: The Transfer of American Academy of Pediatrics Policy Statement: The Transfer of American Academy of Pediatrics Policy Statement: The Transfer of Drugs and Other Chemicals Into Human Milk Drugs and Other Chemicals Into Human Milk http://aappolicy.aappublications.org/cgi/ http://aappolicy.aappublications.org/cgi/ content/full/pediatrics%3b108/3/776 content/full/pediatrics%3b108/3/776 pp MICROMEDEX Healthcare Series MICROMEDEX Healthcare Series (Subscription Required) (Subscription Required) 12 12 (Subscription Required) (Subscription Required) http://www.micromedex.com/products/hcs/ http://www.micromedex.com/products/hcs/ DRUG FACTORS DRUG FACTORS--II G l G id li G l G id li General Guidelines General Guidelines 1. 1. Most drugs appear in breast milk to some degree Most drugs appear in breast milk to some degree 22 Levels of most drugs in breast milk do not usually Levels of most drugs in breast milk do not usually 2. 2. Levels of most drugs in breast milk do not usually Levels of most drugs in breast milk do not usually exceed 1% to 2% of ingested maternal dosage exceed 1% to 2% of ingested maternal dosage 33 If the milk/plasma ratio of drug and active If the milk/plasma ratio of drug and active 3. 3. If the milk/plasma ratio of drug and active If the milk/plasma ratio of drug and active metabolites is less than 1:1, it is metabolites is less than 1:1, it is usually usually safe to safe to breastfeed breastfeed 4. 4. If infant dose is less than 10% of maternal dose If infant dose is less than 10% of maternal dose (weight adjusted), it is usually safe to breastfeed (weight adjusted), it is usually safe to breastfeed 13 13 DRUG FACTORS DRUG FACTORS--II II Pharmacokinetics Pharmacokinetics 1. 1. Volume of Distribution Volume of Distribution (1 (1--20 L/Kg) 20 L/Kg) pH (breast milk more acidic) pH (breast milk more acidic) 2. 2. pH (breast milk more acidic) pH (breast milk more acidic) 3. 3. Lipids Lipids 44 Protein Protein--BoundDrugs (85%) BoundDrugs (85%) 4. 4. Protein Protein--Bound Drugs (85%) Bound Drugs (85%) 5. 5. Molecular Size (Daltons) Molecular Size (Daltons) (200 (200--400) 400) 6. 6. Active Transport Active Transport 14 14 MATERNAL FACTORS MATERNAL FACTORS Pharmacodynamics Pharmacodynamics 1. 1. Mammary epithelium may have drug Mammary epithelium may have drug -- metabolizing capacity metabolizing capacity g p y g p y 2. 2. Milk volume is usually greatest in the Milk volume is usually greatest in the early morning early morning early morning early morning 3. 3. Fat content of milk is usually highest in Fat content of milk is usually highest in the late morning the late morning 44 Stage of breastfeeding is factor Stage of breastfeeding is factor 15 15 4. 4. Stage of breastfeeding is factor Stage of breastfeeding is factor Stage of Breastfeeding Stage of Breastfeeding Stage of Breastfeeding Stage of Breastfeeding Newborns feed every 1 Newborns feed every 1--2 hours 2 hours Newborns feed every 1 Newborns feed every 1 2 hours 2 hours Colostrum (0 Colostrum (0- -3 days) 3 days) T iti l Milk (4 T iti l Milk (4 7 d ) 7 d ) Transitional Milk (4 Transitional Milk (4--7 days) 7 days) Mature Milk (7 Mature Milk (7- -10 days) 10 days) Alveolar Spaces (0 Alveolar Spaces (0- -7 days) 7 days) 16 16 INFANT FACTORS INFANT FACTORS Pharmacodynamics Pharmacodynamics 1. 1. Infants ability to absorb drug Infants ability to absorb drug Infants ability to detoxify and excrete Infants ability to detoxify and excrete 2. 2. Infants ability to detoxify and excrete Infants ability to detoxify and excrete the drug the drug 17 17 Photo Courtesy of NIH Photo Courtesy of NIH 18 18 QUESTIONS TO ASK IN DRUG / BREASTFEEDING SITUATIONS 1. What is the name, strength, and dosage of the drug? 2. Do you still have the prescription? Or, have you already filled it and are taking the drug? 3. Why is the drug being prescribed? 4. Do you feel you need to take the drug? 5. What does your doctor say regarding breastfeeding y y g g g outcome and taking the drug? 6. What is the drug dosage schedule and how often do 19 19 you nurse? QUESTIONS TO ASK IN DRUG / BREASTFEEDING SITUATIONS (continued) 7. How old is your baby? 8. Was your baby full-term or premature? 9. What is your baby's weight? 10. Is your baby currently receiving any medication? 11. Do you knowhowto hand-express breast milk or 11. Do you know how to hand express breast milk or do you have access to a breast pump? 12. Is this your first breastfed baby? 20 20 y y STEPWISE APPROACH TO MINIMIZING INFANT DRUG EXPOSURE 1. Withhold the drug 2. Try nondrug therapy 3. Delay therapy 4. Choose drugs that pass poorly into breast milk 4. Choose drugs that pass poorly into breast milk 5. Choose more breastfeeding compatible dosage forms dosage forms 21 21 STEPWISE APPROACH TO MINIMIZING STEPWISE APPROACH TO MINIMIZING INFANT DRUG EXPOSURE INFANT DRUG EXPOSURE INFANT DRUG EXPOSURE INFANT DRUG EXPOSURE (continued) (continued) 66 Choose an alternative route of Choose an alternative route of 66.. Choose an alternative route of Choose an alternative route of administration administration 77 Avoid nursing at times of peak drug Avoid nursing at times of peak drug 7. 7. Avoid nursing at times of peak drug Avoid nursing at times of peak drug concentrations in milk concentrations in milk 88 Administer drug immediately after Administer drug immediately after 8. 8. Administer drug immediately after Administer drug immediately after breastfeeding and / or before infant's breastfeeding and / or before infant's l t l l t l longest sleep longest sleep 9. 9. Temporarily withhold breastfeeding Temporarily withhold breastfeeding 22 22 10. Discontinue breastfeeding (wean) 10. Discontinue breastfeeding (wean) Photo Courtesy of NIH Photo Courtesy of NIH 23 23 CASE STUDY CASE STUDY CASE STUDY CASE STUDY Mrs Maine a breastfeeding woman Mrs Maine a breastfeeding woman Mrs. Maine, a breastfeeding woman, Mrs. Maine, a breastfeeding woman, presents a prescription. She is presents a prescription. She is worried about taking this medication worried about taking this medication worried about taking this medication worried about taking this medication while breastfeeding and asks for my while breastfeeding and asks for my recommendation She wants to know recommendation She wants to know recommendation. She wants to know recommendation. She wants to know if the antibiotic is safe to take while if the antibiotic is safe to take while breastfeeding her baby Augusta breastfeeding her baby Augusta breastfeeding her baby, Augusta. breastfeeding her baby, Augusta. 24 24 CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) After asking the mother several questions After asking the mother several questions After asking the mother several questions After asking the mother several questions about herself and her baby, the mother about herself and her baby, the mother states that she will be back in two hours to states that she will be back in two hours to states that she will be back in two hours to states that she will be back in two hours to pick up her filled prescription if I determine pick up her filled prescription if I determine that the drug is usually safe to take while that the drug is usually safe to take while that the drug is usually safe to take while that the drug is usually safe to take while breastfeeding. breastfeeding. What questions should be asked the What questions should be asked the What questions should be asked the What questions should be asked the mother? mother? 25 25 CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) Fromthe mother I was able to obtain the Fromthe mother I was able to obtain the From the mother, I was able to obtain the From the mother, I was able to obtain the following information: following information: The mother weighs 110 pounds (50 Kg) The mother weighs 110 pounds (50 Kg) The mother weighs 110 pounds (50 Kg). The mother weighs 110 pounds (50 Kg). The mother and baby have no drug The mother and baby have no drug allergies Her baby is seven months old allergies Her baby is seven months old allergies. Her baby is seven months old, allergies. Her baby is seven months old, taking no medications, and weighs 22 taking no medications, and weighs 22 pounds (10 Kg) Breastfeeding is going pounds (10 Kg) Breastfeeding is going pounds (10 Kg). Breastfeeding is going pounds (10 Kg). Breastfeeding is going very well. very well. 26 26 CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) The prescription is for: Xybotic The prescription is for: Xybotic The prescription is for: Xybotic, The prescription is for: Xybotic, 1000 mg every twelve hours for five 1000 mg every twelve hours for five d (2000 d ) d (2000 d ) days (2000 mg per day). days (2000 mg per day). 27 27 CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) I amunable to find any AAP I amunable to find any AAP I am unable to find any AAP I am unable to find any AAP recommendation regarding Xybotic. recommendation regarding Xybotic. What is my next step? What is my next step? 28 28 CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) I run a computer search on Xybotic and I run a computer search on Xybotic and I run a computer search on Xybotic and I run a computer search on Xybotic and come up with the following information: come up with the following information: Xybotic is 90 percent bound to plasma Xybotic is 90 percent bound to plasma Xybotic is 90 percent bound to plasma Xybotic is 90 percent bound to plasma protein, has a fairly low fat solubility, has a protein, has a fairly low fat solubility, has a volume of distribution of 1400 L has a volume of distribution of 1400 L has a volume of distribution of 1400 L, has a volume of distribution of 1400 L, has a molecular mass (size) of 300 Daltons, molecular mass (size) of 300 Daltons, peaks in plasma in one hour and has a peaks in plasma in one hour and has a peaks in plasma in one hour, and has a peaks in plasma in one hour, and has a half half--life of four hours. life of four hours. 29 29 CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) Protein: + Protein: + Protein: Protein: Fat Solubility: + Fat Solubility: + Daltons: +/ Daltons: +/ Daltons: +/ Daltons: +/-- Volume of Distribution: + Volume of Distribution: + P k A id b tf di 0 P k A id b tf di 0 2 h ft 2 h ft Peak: Avoid breastfeeding 0 Peak: Avoid breastfeeding 0--2 hours after 2 hours after dose, if possible dose, if possible H lf H lf Lif Sh ld t l t i b b Lif Sh ld t l t i b b Half Half--Life: Should not accumulate in baby Life: Should not accumulate in baby 30 30 CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) I also amable to find a reference to one I also amable to find a reference to one I also am able to find a reference to one I also am able to find a reference to one study that states that when five mothers study that states that when five mothers took Xybotic an average of 0 01 mg of took Xybotic an average of 0 01 mg of took Xybotic, an average of 0.01 mg of took Xybotic, an average of 0.01 mg of the drug appeared in 1 ml (10 mg/L) of the drug appeared in 1 ml (10 mg/L) of breast milk breast milk breast milk. breast milk. Mothers wt. adjusted dose: 40mg/Kg/day Mothers wt. adjusted dose: 40mg/Kg/day B b t dj t d d 1 /K /d B b t dj t d d 1 /K /d Babys wt. adjusted dose: 1 mg/Kg/day Babys wt. adjusted dose: 1 mg/Kg/day Baby/Mother Percentage = 2.5% (1/40) Baby/Mother Percentage = 2.5% (1/40) 31 31 Photo Courtesy of NIH Photo Courtesy of NIH 32 32 CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) What recommendation would you What recommendation would you What recommendation would you What recommendation would you provide to Mrs. Maine as you counsel provide to Mrs. Maine as you counsel h ? h ? her? her? What would you have done if the drug What would you have done if the drug y g y g was not compatible with was not compatible with breastfeeding? breastfeeding? breastfeeding? breastfeeding? 33 33 Recommendation Recommendation Recommendation Recommendation OK to breastfeed while taking OK to breastfeed while taking OK to breastfeed while taking OK to breastfeed while taking Xybotic Xybotic Observe for possible adverse effects Observe for possible adverse effects Observe for possible adverse effects Observe for possible adverse effects in child (diarrhea or possible allergic in child (diarrhea or possible allergic reaction) reaction) reaction) reaction) Not necessary, but can avoid Not necessary, but can avoid b tf di til 2 h ft b tf di til 2 h ft breastfeeding until 2 hours after breastfeeding until 2 hours after taking drug taking drug 34 34 What Else Could You Do? What Else Could You Do? What Else Could You Do? What Else Could You Do? Look for breastfeeding Look for breastfeeding Look for breastfeeding Look for breastfeeding compatible alternative in the compatible alternative in the d t ( H l d t ( H l same drug category (e.g., Hale same drug category (e.g., Hale and LactMed suggest and LactMed suggest alternatives) alternatives) If no alternative drug, go If no alternative drug, go If no alternative drug, go If no alternative drug, go through the Stepwise Approach through the Stepwise Approach 35 35 Photo Courtesy of NIH Photo Courtesy of NIH 36 36 CONSIDERATIONS: CONSIDERATIONS: P i i D P i i D Prescription Drugs Prescription Drugs Analgesics Analgesics gg Nonnarcotic Nonnarcotic Narcotic Narcotic General and Epidural General and Epidural Anti Anti--Infectives Infectives Antihistamines/ Antihistamines/ Decongestants Decongestants Decongestants Decongestants Bronchodilators Bronchodilators Corticosteroids Corticosteroids Antihypertensives Antihypertensives Cardiac Drugs Cardiac Drugs 37 37 CONSIDERATIONS: CONSIDERATIONS: Prescription Drugs Prescription Drugs Anticoagulants Anticoagulants gg Diuretics Diuretics Antidiabetics Antidiabetics Th id/A ti Th id/A ti Th id D Th id D Thyroid/Anti Thyroid/Anti--Thyroid Drugs Thyroid Drugs Hormone Contraceptives Hormone Contraceptives Gastrointestinal Drugs Gastrointestinal Drugs Gastrointestinal Drugs Gastrointestinal Drugs Psychotherapeutic Drugs Psychotherapeutic Drugs Benzodiazepines Benzodiazepines Antiepileptics Antiepileptics Radiopharmaceuticals Radiopharmaceuticals Miscellaneous Drugs Miscellaneous Drugs 38 38 Miscellaneous Drugs Miscellaneous Drugs SSRIs SSRIs SSRIs SSRIs 11 Sertraline (Zoloft) Sertraline (Zoloft) 11. Sertraline (Zoloft) . Sertraline (Zoloft) 2. Escitalopram (Lexapro) 2. Escitalopram (Lexapro) 2 Paroxetine (Paxil) 2 Paroxetine (Paxil) 2. Paroxetine (Paxil) 2. Paroxetine (Paxil) 4. Venlafaxine (Effexor) 4. Venlafaxine (Effexor) 5 Fluvoxamine (Luvox) 5 Fluvoxamine (Luvox) 5. Fluvoxamine (Luvox) 5. Fluvoxamine (Luvox) 6. Citalopram (Celexa) 6. Citalopram (Celexa) 7 Fl ti (P ) 7 Fl ti (P ) 7. Fluoxetine (Prozac) 7. Fluoxetine (Prozac) 39 39 ADVERSE EFFECTS ADVERSE EFFECTS (Overall Rate: 1%) (Overall Rate: 1%) Psychotherapeutics (Antidepressants, Sedatives, Psychotherapeutics (Antidepressants, Sedatives, Antipsychotics): 31% Antipsychotics): 31% Antimicrobials: 17% Antimicrobials: 17% Anticonvulsants: 16% Anticonvulsants: 16% Anticonvulsants: 16% Anticonvulsants: 16% Analgesics (NSAIDs, Opioids): 12% Analgesics (NSAIDs, Opioids): 12% Hormonal Drugs: 5% Hormonal Drugs: 5% Iodides: 5% Iodides: 5% Iodides: 5% Iodides: 5% Cardiovascular Drugs: 4% Cardiovascular Drugs: 4% GIT Drugs: 2% GIT Drugs: 2% Antihistamines: 2% Antihistamines: 2% Chemotherapeutics: 2% Chemotherapeutics: 2% 40 40 ADVERSE EFFECTS ADVERSE EFFECTS ADVERSE EFFECTS ADVERSE EFFECTS Psychotherapeutics (Antidepressants, Sedatives, Psychotherapeutics (Antidepressants, Sedatives, Antipsychotics): Drowsiness Antipsychotics): Drowsiness Antimicrobials: Diarrhea Antimicrobials: Diarrhea Anticonvulsants: Drowsiness, sedation, poor feeding Anticonvulsants: Drowsiness, sedation, poor feeding Anticonvulsants: Drowsiness, sedation, poor feeding Anticonvulsants: Drowsiness, sedation, poor feeding Analgesics (NSAIDs, Opioids): Drowsiness, sedation Analgesics (NSAIDs, Opioids): Drowsiness, sedation Hormonal Drugs: Decreased milk supply, volume, Hormonal Drugs: Decreased milk supply, volume, quantity quantity quantity quantity Iodides: Thyroid suppression Iodides: Thyroid suppression Cardiovascular Drugs: Weakness, hypotension, Cardiovascular Drugs: Weakness, hypotension, bradycardia bradycardia bradycardia bradycardia GIT Drugs: GIT upset GIT Drugs: GIT upset Antihistamines: Irritability, drowsiness Antihistamines: Irritability, drowsiness 41 41 Chemotherapeutics: Toxic effects of treatment Chemotherapeutics: Toxic effects of treatment ADVERSE EFFECTS ADVERSE EFFECTS (R f ) (R f ) (References) (References) Anderson PO, Pochop SL, Manoguerra AS: Anderson PO, Pochop SL, Manoguerra AS: , p , g , p , g Adverse drug reactions in breastfed infants: less Adverse drug reactions in breastfed infants: less than imagined. Clin Ped: 42 (4), 325 than imagined. Clin Ped: 42 (4), 325--40: 2003 40: 2003 I S Bl j h A S h M l I S Bl j h A S h M l Ito S, Blajchman A, Stephenson M, et al: Ito S, Blajchman A, Stephenson M, et al: Prospective follow Prospective follow--up of adverse reactions in up of adverse reactions in breast breast--fed infants exposed to maternal fed infants exposed to maternal breast breast fed infants exposed to maternal fed infants exposed to maternal medication. Am J Obstet Gynecol: 168 (5), medication. Am J Obstet Gynecol: 168 (5), 1393 1393--9: 1993 9: 1993 42 42 Codeine Rapid Metabolizers Codeine Rapid Metabolizers Codeine Rapid Metabolizers Codeine Rapid Metabolizers 13 13--day breastfed baby dies from day breastfed baby dies from 13 13 day breastfed baby dies from day breastfed baby dies from morphine overdose in breast milk in morphine overdose in breast milk in mother taking codeine mother taking codeine mother taking codeine mother taking codeine How did that ever happen? How did that ever happen? 43 43 ABMClinical Protocol #15 ABMClinical Protocol #15 ABM Clinical Protocol #15 ABM Clinical Protocol #15 Academy of Breastfeeding Medicine Clinical Academy of Breastfeeding Medicine Clinical Protocol #15: Protocol #15: Protocol #15: Protocol #15: Analgesia and Anesthesia for the Breastfeeding Analgesia and Anesthesia for the Breastfeeding Mother Mother Anne Montgomery, Thomas W. Hale, and The Anne Montgomery, Thomas W. Hale, and The Academy of Breastfeeding Medicine Protocol Academy of Breastfeeding Medicine Protocol Committee Committee Committee Committee Reprint Requests: abm@bfmed.org Reprint Requests: abm@bfmed.org http://www.bfmed.org/Resources/ http://www.bfmed.org/Resources/ p // g/ / p // g/ / Protocols.aspx Protocols.aspx 44 44 CONSIDERATIONS: CONSIDERATIONS: OTC M di i OTC M di i OTC Medications OTC Medications Analgesics Analgesics Anti Anti--Diarrheal Preparations Diarrheal Preparations Analgesics Analgesics Cough, Cold, and Allergy Cough, Cold, and Allergy Preparations Preparations C h d C ld L C h d C ld L Anti Anti Diarrheal Preparations Diarrheal Preparations Nausea and Vomiting / Motion Nausea and Vomiting / Motion Sickness Preparations Sickness Preparations Hemorrhoidal Preparations Hemorrhoidal Preparations Cough and Cold Lozenges Cough and Cold Lozenges and Sprays and Sprays Nasal Preparations Nasal Preparations Hemorrhoidal Preparations Hemorrhoidal Preparations Sleep Preparations Sleep Preparations Stimulants Stimulants A tit S t P d t A tit S t P d t pp Asthma Preparations Asthma Preparations Antacids and Digestive Aids Antacids and Digestive Aids Appetite Suppressant Products Appetite Suppressant Products Insulin Preparations Insulin Preparations Artificial Sweeteners Artificial Sweeteners Laxatives / Stool Softeners Laxatives / Stool Softeners Miscellaneous OTCs Miscellaneous OTCs 45 45 OTC OTC BREASTFEEDING COUNSELING BREASTFEEDING COUNSELING BREASTFEEDING COUNSELING BREASTFEEDING COUNSELING GUIDELINES GUIDELINES Avoid taking OTC medications for which safer products Avoid taking OTC medications for which safer products g p g p are available. are available. Avoid taking OTC medications for which little Avoid taking OTC medications for which little breastfeeding information is available. breastfeeding information is available. breastfeeding information is available. breastfeeding information is available. Avoid taking combination OTCs, which are those with Avoid taking combination OTCs, which are those with multiple ingredients (it is better for the mother to take an multiple ingredients (it is better for the mother to take an OTC that has the one or two specific ingredients that will OTC that has the one or two specific ingredients that will OTC that has the one or two specific ingredients that will OTC that has the one or two specific ingredients that will treat her specific condition; there is no need for the treat her specific condition; there is no need for the mothers or nurslings to be exposed to unnecessary mothers or nurslings to be exposed to unnecessary ingredients) ingredients) ingredients). ingredients). 46 46 OTC OTC BREASTFEEDING COUNSELING BREASTFEEDING COUNSELING BREASTFEEDING COUNSELING BREASTFEEDING COUNSELING GUIDELINES GUIDELINES Avoid taking extra strength forms of OTC medications Avoid taking extra strength forms of OTC medications g g g g (there is no need for the nursling to be exposed to extra (there is no need for the nursling to be exposed to extra amounts of a drug when it is not needed). amounts of a drug when it is not needed). Avoid taking long Avoid taking long--acting OTC medications (there is no acting OTC medications (there is no Avoid taking long Avoid taking long acting OTC medications (there is no acting OTC medications (there is no need for the nursling to be exposed to a drug for a longer need for the nursling to be exposed to a drug for a longer period of time, especially if an adverse reaction is period of time, especially if an adverse reaction is possible in the nursling) possible in the nursling) possible in the nursling). possible in the nursling). The mother should know about possible side effects that The mother should know about possible side effects that might occur in her nursling, as well as herself. might occur in her nursling, as well as herself. If ibl ith i ti d th th h ld If ibl ith i ti d th th h ld If possible, as with prescription drugs, the mother should If possible, as with prescription drugs, the mother should use a nondrug approach for treating her symptoms. use a nondrug approach for treating her symptoms. 47 47 CONSIDERATIONS: CONSIDERATIONS: H b l (M j G l ) H b l (M j G l ) Herbals (Major Galactogogues) Herbals (Major Galactogogues) Chaste Tree Chaste Tree Chaste Tree Chaste Tree Fennel Fennel Fenugreek Fenugreek Fenugreek Fenugreek Garlic Garlic Goat's Rue Goat's Rue Milk Thistle / Blessed Thistle Milk Thistle / Blessed Thistle 48 48 CONSIDERATIONS: CONSIDERATIONS: H b l (Mi G l ) H b l (Mi G l ) Herbals (Minor Galactogogues) Herbals (Minor Galactogogues) Anise Anise Marshmallow Marshmallow Anise Anise Borage Borage Alfalfa Alfalfa Marshmallow Marshmallow Nettle Nettle Hops Hops Alfalfa Alfalfa Caraway Caraway Coriander Coriander Hops Hops Oat Straw Oat Straw Red Clover Red Clover Coriander Coriander Dandelion Dandelion Dill Dill Red Clover Red Clover Red Raspberry Red Raspberry Vervain Vervain Dill Dill Vervain Vervain 49 49 CONSIDERATIONS: CONSIDERATIONS: H b l H b l Herbals Herbals Analgesics Analgesics Bugleweed, Comfrey Bugleweed, Comfrey Headache (Migraine) Agents Headache (Migraine) Agents Feverfew Feverfew Feverfew Feverfew Anti Anti--Anxiety Agents Anxiety Agents Indian Snakeroot, Kava Kava, Passionflower, Indian Snakeroot, Kava Kava, Passionflower, St J ohns Wort Valerian St J ohns Wort Valerian St. J ohns Wort, Valerian St. J ohns Wort, Valerian Stimulants Stimulants Ginseng Root, Siberian Ginseng, Ginkgo Biloba, Ginseng Root, Siberian Ginseng, Ginkgo Biloba, A li R t / D Q i A li R t / D Q i Angelica Root / Dong Quai Angelica Root / Dong Quai Sleep Preparations Sleep Preparations Melatonin Melatonin 50 50 CONSIDERATIONS: CONSIDERATIONS: H b l H b l Herbals Herbals Cough, Cold, and Allergy Products Cough, Cold, and Allergy Products Coltsfoot, Echinacea, Elder Flower Coltsfoot, Echinacea, Elder Flower Gastrointestinal Agents Gastrointestinal Agents Gastrointestinal Agents Gastrointestinal Agents Aloe, Buckthorn, Cascara Sagrada, Chamomile, Aloe, Buckthorn, Cascara Sagrada, Chamomile, Flaxseed, Licorice, Psyllium Seed, Rhubarb, Senna Flaxseed, Licorice, Psyllium Seed, Rhubarb, Senna Nausea and Vomiting Preparations Nausea and Vomiting Preparations Nausea and Vomiting Preparations Nausea and Vomiting Preparations Ginger Ginger Lipid Lowering Agents Lipid Lowering Agents S L ithi S L ithi Soy Lecithin Soy Lecithin Urinary Tract Preparations Urinary Tract Preparations Goldenrod, Petasites, Uva Ursi Goldenrod, Petasites, Uva Ursi 51 51 CONSIDERATIONS: CONSIDERATIONS: R i l D R i l D Recreational Drugs Recreational Drugs Amphetamine / Methylphenidate Amphetamine / Methylphenidate p yp p yp Marijuana Marijuana Cocaine Cocaine Cocaine Cocaine Phencyclidine Phencyclidine Narcotics Narcotics Caffeine Caffeine Alcohol Alcohol Nicotine Nicotine 52 52 Nicotine Nicotine RECREATIONAL DRUGS RECREATIONAL DRUGS RECREATIONAL DRUGS RECREATIONAL DRUGS Fromboth a philosophical and scientific Fromboth a philosophical and scientific From both a philosophical and scientific From both a philosophical and scientific viewpoint, recreational drugs of abuse viewpoint, recreational drugs of abuse should be should be contraindicated during contraindicated during should be should be contraindicated during contraindicated during breastfeeding breastfeeding as they are hazardous, not as they are hazardous, not only to the nursling but to the mother as only to the nursling but to the mother as only to the nursling, but to the mother as only to the nursling, but to the mother as well. well. 53 53 FINAL CONSIDERATIONS FINAL CONSIDERATIONS Only essential drugs should be taken by the i th Sh h ld b nursing mother. She should be knowledgeable of and be encouraged to report any adverse effects any adverse effects For newer drugs, sufficient information is often g , unavailable. If information is available, it requires careful interpretation and evaluation Recognizing the benefits of continuing to nurse in most cases drugs that have safe 54 54 nurse, in most cases, drugs that have safe therapeutic levels can be given Courtesy of NIH Courtesy of NIH 55 55 J APhA Article J APhA Article J APhA Article J APhA Article Nice FJ Luo AC: Medications and Nice FJ Luo AC: Medications and Nice FJ, Luo AC: Medications and Nice FJ, Luo AC: Medications and Breast Breast- -feeding: Current Concepts. feeding: Current Concepts. Journal of the American Pharmacists Journal of the American Pharmacists Journal of the American Pharmacists Journal of the American Pharmacists Association. 52: 86 Association. 52: 86- -94 94 (January/February) 2012 (January/February) 2012 (January/February) 2012. (January/February) 2012. 56 56 PUBLICATIONS PUBLICATIONS PUBLICATIONS PUBLICATIONS Nice FJ: Common Herbs and Foods Nice FJ: Common Herbs and Foods Used as Galactogogues ICAN: Used as Galactogogues ICAN: Used as Galactogogues. ICAN: Used as Galactogogues. ICAN: Infant, Child, & Adolescent Nutrition, Infant, Child, & Adolescent Nutrition, 3: 129 3: 129 132 (June) 2011 132 (June) 2011 3: 129 3: 129--132 (June) 2011. 132 (June) 2011. PUBLICATIONS PUBLICATIONS PUBLICATIONS PUBLICATIONS Nice FJ, DeEugenio D, DiMino TA, Freeny IC, Nice FJ, DeEugenio D, DiMino TA, Freeny IC, , g , , y , , g , , y , Rovnack MB, and Gromelski JS: Rovnack MB, and Gromelski JS: Medications and Breast Medications and Breast- -Feeding: A Guide Feeding: A Guide for Pharmacists, Pharmacy Technicians, and for Pharmacists, Pharmacy Technicians, and Other Healthcare Professionals, Other Healthcare Professionals, Part I Part I. . J l f Ph T h l J l f Ph T h l 20 17 20 17 27 27 Journal of Pharmacy Technology Journal of Pharmacy Technology, 20: 17 , 20: 17--27 27 (January/February) 2004. (January/February) 2004. 58 58 PUBLICATIONS PUBLICATIONS PUBLICATIONS PUBLICATIONS NNice FJ DeEugenio D DiMino TA Freeny ice FJ DeEugenio D DiMino TA Freeny NNice FJ, DeEugenio D, DiMino TA, Freeny ice FJ, DeEugenio D, DiMino TA, Freeny IC, Rovnack MB, and Gromelski JS: IC, Rovnack MB, and Gromelski JS: Medications and Breast Medications and Breast--Feeding: A Guide Feeding: A Guide Medications and Breast Medications and Breast Feeding: A Guide Feeding: A Guide for Pharmacists, Pharmacy Technicians, and for Pharmacists, Pharmacy Technicians, and Other Healthcare Professionals, Other Healthcare Professionals, Part II Part II. . Journal of Pharmacy Technology Journal of Pharmacy Technology, 20: 85 , 20: 85- -95 95 (March/April) 2004 (March/April) 2004.. 59 59 PUBLICATIONS PUBLICATIONS PUBLICATIONS PUBLICATIONS Nice FJ, DeEugenio D, DiMino TA, Freeny IC, Nice FJ, DeEugenio D, DiMino TA, Freeny IC, Nice FJ, DeEugenio D, DiMino TA, Freeny IC, Nice FJ, DeEugenio D, DiMino TA, Freeny IC, Rovnack MB, and Gromelski JS: Rovnack MB, and Gromelski JS: Medications and Breast Medications and Breast- -Feeding: A Guide for Feeding: A Guide for gg Pharmacists, Pharmacy Technicians, and Pharmacists, Pharmacy Technicians, and Other Healthcare Professionals, Other Healthcare Professionals, Part III Part III. . Journal of Pharmacy Technology Journal of Pharmacy Technology, 20: 165 , 20: 165- -177 177 (May/June) 2004. (May/June) 2004. 60 60 PUBLICATIONS PUBLICATIONS PUBLICATIONS PUBLICATIONS Nice FJ: Over Nice FJ: Over- -the the--Counter Medication Use During Counter Medication Use During Breastfeeding Breastfeeding Pharmacy Times Pharmacy Times 67:46 48 67:46 48--49 49 Breastfeeding. Breastfeeding. Pharmacy Times Pharmacy Times, 67:46,48 , 67:46,48 49 49 (January) 2001. (January) 2001. Nice FJ Snyder JL and Kotansky BC: Breastfeeding Nice FJ Snyder JL and Kotansky BC: Breastfeeding Nice FJ, Snyder JL, and Kotansky BC: Breastfeeding Nice FJ, Snyder JL, and Kotansky BC: Breastfeeding and Over and Over- -the the--Counter Medications. Counter Medications. Journal of Journal of Human Lactation Human Lactation, 16: 319 , 16: 319- -331 (November) 2000. 331 (November) 2000. Nice FJ, Coghlan RJ, and Birmingham BT: Herbals Nice FJ, Coghlan RJ, and Birmingham BT: Herbals and Breastfeeding: Which Herbals Are Safe To Take and Breastfeeding: Which Herbals Are Safe To Take While Breastfeeding? While Breastfeeding? Birth Issues Journal Birth Issues Journal 9:77 9:77--84 84 While Breastfeeding? While Breastfeeding? Birth Issues Journal Birth Issues Journal, 9:77 , 9:77 84 84 (September/October) 2000. (September/October) 2000. 61 61 PUBLICATIONS PUBLICATIONS PUBLICATIONS PUBLICATIONS Nice FJ, Coghlan RJ, and Birmingham BT: Herbals Nice FJ, Coghlan RJ, and Birmingham BT: Herbals Nice FJ, Coghlan RJ, and Birmingham BT: Herbals Nice FJ, Coghlan RJ, and Birmingham BT: Herbals and Breastfeeding. and Breastfeeding. U.S. Pharmacist U.S. Pharmacist, 25: 28, 31 , 25: 28, 31- - 32, 24, 41 32, 24, 41- -42, 45 42, 45- -46 (September) 2000. 46 (September) 2000. Nice FJ, Pincock L, and Nguyen ME: Medications Nice FJ, Pincock L, and Nguyen ME: Medications and Breastfeeding: What Pharmacists Can Tell and Breastfeeding: What Pharmacists Can Tell and Breastfeeding: What Pharmacists Can Tell and Breastfeeding: What Pharmacists Can Tell Nursing Mothers. Nursing Mothers. Pharmacy Times Pharmacy Times, 65: 52, 55 , 65: 52, 55- - 58, 61 58, 61- -62, 64 62, 64- -66, 68, 70, 72 (September) 1999. 66, 68, 70, 72 (September) 1999. 62 62 Thank you for your participation Thank you for your participation Thank you for your participation Thank you for your participation 63 63
Paroxetine, Cognitive Therapy or Their Combination in The Treatment of Social Anxiety Disorder With and Without Avoidant Personality Disorder: A Randomized Clinical Trial