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Prescribing In Breastfeeding

Question Options Pre-response Reading Final
Analgesia during lactation Codeine contraindicated in rapid metabolisers
NSAIDs highly protein bound and weak acids pass into milk at high concs
Paracetamol has short half-life. Low passage into milk
Tramadol contraindicated in rapid metabolisers		 Tramadol Paracetamol short half life and low passage Paracetamol
What minimised drug exposure to breast-fed baby? M/R formulations
shorter half-life drug
newer drugs as likely to have more data
herbal over prescribed
drug with established safety during pregnancy		 shorter half-life shorter half-life
Prolactin production inhibited by Dopamine. Which will increase milk production Metoclopramide
Bromocriptine
Olanzipine		 Metoclopramide Bromo suppresses Metoclopramide
34 yr 3-weeks post partum and feeding. Prev on Microgynon and needle-phobic. What is most appropriate contraceptive Combined oral contraceptive pill
Intra-uterine device
Intra-uterine system (Mirena)
Progesterone only contraceptive
Don't start today. Use barrier methods for a week		 Intra-uterine device Wait a week Progesterone only
28 yr old 3/52 post-partum and feeding. Hx of facial acne on oxytetracycline 500mg bd. Asks if she can restart. Correct statement about tetracyclines for short courses All safe
Doxycycline
Lymecycline
Oxytetracycline
Tetracycline		 Doxycycline Tetracycline
Correct statement High protein binding more likely to pass into milk
High molecular weight more likely to pass into milk
High lipid solubility more likely to accumulate in milk
Low plasma concentration more likely to be a problem		 Lipids Lipids Lipids
Oral antihistamine for seasonal allergic rhinitis when steroid nasal spray has failed Cetirizine
Chlorphenamine
Cyclizine
Fexofenadine
Hydroxyzine		 Chlorphenamine Cetirizine Cetirizine
35 yr w/ 2/12 boy. PMH depression on St John Wort which was stopped dyring pregnancy. finding it hard to cope. Baby is well. What is first line for depression Amitriptyline
Fluoxetine
Sertraline
St John's Wort
venlafaxine		 Sertraline Sertraline Sertraline
Which vaccine is contraindicated in breastfeeding Flu
Pertussis
Pneumococcal
Yellow Fever		 Yellow Fever Yellow Fever Yellow Fever
DHSC recommends infants are exclusively fed till what age 3/12
6/12
9/12
1 year
2 years		 9/12 6/12 6/12

50%

Learning Outcomes

  • Discuss the risks and benefits of prescribing in patients who are breastfeeding, considering the gestational age of the infant and both the infant's and mother's comorbidities.
  • Describe the ways in which exposure to drug therapy via breast milk may be minimised.
  • List some drugs known to suppress lactation and describe how they may be used therapeutically.
  • Identify the sources of advice available to guide your decision-making when prescribing for this group of patients.

Tools

Use of medicines in pregnancy and breastfeeding

Key Points

  • There are enormous benefits of breastfeeding for both mother and child.
  • Avoiding breastfeeding to take medication should not be considered a neutral no harm option.
  • Drugs have the potential to enter breast milk and cause pharmacological effects in the breastfed infant.
  • By following some key prescribing principles, breastfeeding rarely needs to cease.
  • A drug that is safe to use during pregnancy does not necessarily mean that it is safe for use during breastfeeding.
  • Some drugs can reduce the production of breast milk.
  • Consult reputable sources of information when prescribing for women who are breastfeeding.

Principles

  • Consider if the drug treatment is necessary in the first place.
  • Avoid using herbal preparations as the actual content is not always known and there is a lack of data to support safe use.
  • Avoid drugs known to cause serious toxicity in adults or children.
  • If a drug is licensed for use in children or has an established dose regimen listed in an appropriate resource (e.g. BNFC), the therapeutic dose can be- compared to the estimated dose received via breast milk.
  • Be particularly cautious about prescribing in premature neonates/infants due to reduced excretory and metabolic functions.
  • Choose a regimen (and route) that minimises exposure to the drug.
  • Avoid long-acting drugs or preparations (i.e. modified-release). Drugs with a short half-life are preferred for use in breastfeeding.
  • In general, feeding immediately before a dose is due will ensure that the lowest amount of drug is present in the milk, although this is difficult to- achieve with long-acting agents. Delaying feeding (weaned infants only) or using expressed milk / formula for a single feed can also reduce risk and may- be preferable to stopping breastfeeding altogether.
  • Avoid polypharmacy where possible owing to the risk of additive adverse effects.
  • Monitor infants exposed to drugs via breast milk for possible adverse effects.
  • Avoid new drugs for which there is little data supporting safe use during breastfeeding.
  • Bear in mind that most drugs are not licensed for use in breastfeeding mothers.
  • A drug that is safe to use during pregnancy does not necessarily mean that it is safe to use in breastfeeding.

Benefits of Breastfeeding

Individual Benefit
Child Breastfeeding reduces the risk of:
Asthma and other atopic illness
Diarrhoea
Necrotising enterocolitis (NEC)
Obesity and cardiovascular disease in later life
Some acute infections such as otitis media, Haemophilus influenza meningitis and urinary tract infections
Type I and Type II diabetes

Breastfeeding is also thought to increase the child’s IQ.
Mother Breastfeeding reduces the risk of:
Breast and ovarian cancer.
Postnatal depression.
Post-partum haemorrhage.
Type II diabetes.

UNICEF UK Baby Friendly Initiative

Factors affecting Prescribing

Factor Details
Age of Baby Younger at higher risk esp 3-4 days due to low volume produced.
Renal function has impact.
eGFR Term neonates 2-4 ml/min/1.73m2 vs Prem neonates 0.6-0.8
Hepatic Function to do immature metabolism
Baby comorbidities Comorbidities are especially important if they affect renal or hepatic function, or if they affect an organ system that may also be affected by exposure to the drug.
Medication taken This should include any over-the-counter medicines, herbal products and nutritional supplements. Existing medication might alter the effects of the new drug, for example cytochrome P450 enzyme inhibitors and inducers.
Feeding frequency This may range from every 2-3 hours during the first 6 months of life to a single comfort feed at night once the infant has been weaned. This will influence the exposure of the baby to the drug.

Drug Selection

Passage into milk

Characteristics Reduced passage into milk
Molecular Weight High molecular weight - insulin heparins
Protein binding High protein binding - warfarin and NSAIDs
Lipid solubility Low lipid solubility - loratidine
pH Low pH - concetration of acidic drugs in milk is low

Analgesia

  • In general, NSAIDs are highly protein bound and, being weak acids, will pass into breast milk at very low concentrations.
  • Ibuprofen and diclofenac are the preferred choice, based on their extensive safe use during breastfeeding in clinical practice.
  • Opioids should be avoided if possible.
    • Codeine is contraindicated during breastfeeding. There can be inter-individual variation in a person’s ability to metabolise and excrete codeine, influencing the concentration of the drug in breast milk. Rapid metabolisers of codeine may experience opioid toxicity. It should particularly be avoided in anyone who has had dizziness, drowsiness or severe constipation resulting from codeine in the past. An infant fatality has been reported as a result of exposure to opioids via breast milk.
  • If another opioid analgesic is necessary, prescribe for a very short period of time, at the lowest effective dose and under close medical supervision. The breast-fed infant should be monitored for sedation, poor feeding and respiratory depression.
Drug Details
Paracetamol Paracetamol is available for use in neonates from 28-weeks post menstrual age for the treatment of pain and pyrexia.
The passage into breast milk is low.
It has a short half-life of approximately 2 hours.
It is the analgesic of choice during breastfeeding.
NSAIDs In general, NSAIDs are highly protein bound and, being weak acids, will pass into breast milk at very low concentrations.
Ibuprofen and diclofenac are the preferred choice of NSAID, based on their extensive safe use during breastfeeding in clinical practice.
Additionally, ibuprofen may be used in infants from 1 month of age.
Aspirin as an analgesic is best avoided due to the risk of Reye’s syndrome, although the amounts in breast milk are very low. At antiplatelet doses it is believed to be safe.
Codeine Codeine is metabolised in the liver to its active metabolite morphine.
There can be inter-individual variation in a person's ability to metabolise and excrete codeine, influencing the concentration of the drug in breast milk. Rapid metabolisers of codeine may experience opioid toxicity. An infant fatality has been reported as a result of exposure via breast milk. It should particularly be avoided in anyone who has had dizziness, drowsiness or severe constipation resulting from codeine in the past.
Codeine has been contraindicated in breastfeeding mothers by the European and UK regulatory bodies (EMA/ MHRA).
Dihydrocodeine Dihydrocodeine is metabolised to dihydromorphine.
A case of severe respiratory depression was noted in an infant whose mother was taking dihydrocodeine drops for cough. No fatalities have been observed.
An alternative medication should be used if possible, and if used the infant should be closely monitored for sedation, poor feeding and respiratory depression.
Tramadol Tramadol is secreted into breast milk in small amounts.
A small study (75 mothers) demonstrated no adverse effects in the infants.
It is considered safe to use, if necessary, but the mother should be alert to increased sleepiness, limpness, poor feeding or breathing difficulties in her child.

Depression

  • Postnatal depression may interfere with optimal parenting and the development of the child.
  • Depression may also increase the chance that the mother will cease breastfeeding.
  • Individualise antidepressant therapy to the patient. Take into account response to previous therapy and patient preference.
  • Be particularly cautious if the infant is premature or ill.
  • It is important you have confidence in the parent's ability to monitor the infant for any adverse effects. Also involve community healthcare professionals.

Antidepressant choice:

  • The first-line agents for the treatment of depression in breastfeeding mothers are the SSRIs; sertraline and paroxetine.
  • With the exception of doxepin, you can consider TCAs in breastfeeding mothers. Bear in mind that TCAs are generally more sedating than - the SSRIs.
  • Avoid herbal preparations such as St John's Wort. Despite being pharmacologically active, there is a lack of data on its safety.
  • Monitor the infant for any signs of sedation, poor feeding and behavioural changes.
  • Advise the mother that the risk of adverse effects may be further reduced by breastfeeding immediately before drug administration.
  • For the very young infant, one bottle feed may be substituted, at an appropriate time each day, to avoid peak drug concentrations. As a general rule, peak milk concentrations of drugs are seen between 1-3 hour post dose, but there are many exceptions, notably SSRIs where peak levels are seen 6-8 hours post dose. This strategy may be less relevant for drugs with long half lives and seldom necessary except for high dose regimens.

Contraception

  • The combined oral contraceptive pill may affect milk production, although evidence is conflicting. It is thought to be less problematic after 6 months.
  • It should not be started within 3 weeks of delivery or after 6 weeks if other venous thromboembolism risk factors are present in the patient.
  • Progesterone only methods of contraception (progesterone only contraceptive pill, implant and injection) are known to be safe during breastfeeding. They can be started any time after delivery.
  • The intra-uterine system (Mirena®) and all forms of copper coil are also safe whilst breastfeeding, but they should either be inserted within 48 hours of birth or after 4 weeks of birth due to the risk of perforation in the interim period.

Rhinitis

  • When managing allergic rhinitis in the breastfeeding mother, consider the severity of the symptoms; no treatment may be a reasonable option may be sufficient.
  • Topical agents such as intranasal corticosteroid sprays, nasal drops and eye drops should be considered if possible.
    • Sodium cromoglicate for ocular use
    • Nasal decongestants such as xylometazoline
    • Intranasal antihistamines (e.g. azelastine)
    • Intranasal corticosteroids (e.g. fluticasone and beclometasone)
    • The topical corticosteroids are considered particularly effective for nasal congestion. Nasal decongestants are limited by rebound congestion if used for longer than one week.
    • As the amount of drug absorbed topically is minimal, all agents are considered compatible with breastfeeding.
  • Antihistamines are one of the groups of drugs used to treat seasonal allergic rhinitis. These agents reduce rhinorrhoea and sneezing but are considered to be less effective for nasal congestion. The antihistamines may be divided into two groups:
    • Sedating (e.g. chlorphenamine and promethazine)
    • Non-sedating (e.g. cetirizine and loratadine)
  • During breastfeeding, a non-sedating antihistamine is preferred if oral treatment is necessary. These do not cross the blood-brain barrier and should not have sedating effects. Cetirizine or loratadine are the drugs of choice owing to their widespread use.
  • Sedating antihistamines may cause adverse effects in the breastfed infant such as drowsiness and irritability. if a sedating antihistamine is necessary, chlorphenamine may be used, prescribed at the lowest effective dose and for short period of time. The infant monitored for drowsiness and irritability. This should be at the lowest effective dose for the shortest possible time.

References