MEDICATIONS AND MEDICATIONS AND BREASTFEEDING: BREASTFEEDING: [PDF]

SLIDE 1

MEDICATIONS AND MEDICATIONS AND BREASTFEEDING: BREASTFEEDING: BREASTFEEDING: BREASTFEEDING: 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 g 301 301-

840

840-

0270 (H)

0270 (H) 240 240-

506

506-

2568 (C)

2568 (C)

SLIDE 2

OBJECTIVES OBJECTIVES OBJECTIVES OBJECTIVES

Be able to identify the benefits and risks of

Be able to identify the benefits and risks of y 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

2 2

breastfeeding and taking or will take medications breastfeeding and taking or will take medications

SLIDE 3

Photo Courtesy of NIH Photo Courtesy of NIH 3 3

SLIDE 4

Benefit Benefit-Risk Analysis Risk Analysis Benefit Benefit Risk Analysis Risk Analysis

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 g (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)

4 4

SLIDE 5

SOURCES OF INFORMATION SOURCES OF INFORMATION SOURCES OF INFORMATION SOURCES OF INFORMATION

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

Nonprescription Drugs for the Breastfeeding Mother, 2

nprescription Drugs for the Breastfeeding Mother, 2nd

nd Edition

Edition Nice (See Slide) Nice (See Slide) Medications and Mothers’ Milk 15 Medications and Mothers’ Milk 15th

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, 9th

th Edition

Edition Briggs, Freeman, and Yaffe (See Slide) Briggs, Freeman, and Yaffe (See Slide) Drugs and Human Lactation, 2 Drugs and Human Lactation, 2nd

nd Edition

Edition Bennett (WHO) Bennett (WHO)

5 5

SLIDE 6

6 6

SLIDE 7

7 7

SLIDE 8

8 8

SLIDE 9

9 9

SLIDE 10

SOURCES OF INFORMATION SOURCES OF INFORMATION SOURCES OF INFORMATION SOURCES OF INFORMATION

Pharmaceutical Companies

Websites

Websites (See Next Slide) (See Next Slide)

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

SLIDE 11

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 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

SLIDE 12

BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES BREASTFEEDING WEBSITES

Breastfeeding Online

Breastfeeding Online http://breastfeedingonline.com http://breastfeedingonline.com

KellyMom

KellyMom y 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 p

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/

SLIDE 13

DRUG FACTORS DRUG FACTORS-

I

I

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

2

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

3

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

SLIDE 14

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

4

Protein Protein-Bound Drugs (85%) Bound Drugs (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

SLIDE 15

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

4

Stage of breastfeeding is factor Stage of breastfeeding is factor

15 15

4. 4.

Stage of breastfeeding is factor Stage of breastfeeding is factor

SLIDE 16

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

SLIDE 17

INFANT FACTORS INFANT FACTORS

Pharmacodynamics Pharmacodynamics

1. 1.

Infant’s ability to absorb drug Infant’s ability to absorb drug Infant’s ability to detoxify and excrete Infant’s ability to detoxify and excrete

2. 2.

Infant s ability to detoxify and excrete Infant s ability to detoxify and excrete the drug the drug

17 17

SLIDE 18

Photo Courtesy of NIH Photo Courtesy of NIH 18 18

SLIDE 19

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

utcome and taking the drug?

6. What is the drug dosage schedule and how often do

19 19

you nurse?

SLIDE 20

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 know how to 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

SLIDE 21

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

SLIDE 22

STEPWISE APPROACH TO MINIMIZING STEPWISE APPROACH TO MINIMIZING INFANT DRUG EXPOSURE INFANT DRUG EXPOSURE INFANT DRUG EXPOSURE INFANT DRUG EXPOSURE (continued)

(continued)

6 Choose an alternative route of Choose an alternative route of 6. Choose an alternative route of Choose an alternative route of administration administration 7 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 8 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)

SLIDE 23

Photo Courtesy of NIH Photo Courtesy of NIH 23 23

SLIDE 24

CASE STUDY CASE STUDY CASE STUDY CASE STUDY

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

SLIDE 25

CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued)

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

SLIDE 26

CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued)

From the 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

SLIDE 27

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, 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

SLIDE 28

CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued)

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?

28 28

SLIDE 29

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 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

SLIDE 30

CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued)

Protein: +

Protein:

Fat Solubility: +

Daltons: +/

Daltons: +/-

Volume of Distribution: +

Volume of Distribution: + P k A id b tf di 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

SLIDE 31

CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued)

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.

Mother’s wt. adjusted dose: 40mg/Kg/day

Mother’s 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

Baby’s wt. adjusted dose: 1 mg/Kg/day

Baby/Mother Percentage = 2.5% (1/40)

31 31

SLIDE 32

Photo Courtesy of NIH Photo Courtesy of NIH 32 32

SLIDE 33

CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued) CASE STUDY (continued)

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

SLIDE 34

Recommendation Recommendation Recommendation Recommendation

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

SLIDE 35

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 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 through the Stepwise Approach through the Stepwise Approach

35 35

SLIDE 36

Photo Courtesy of NIH Photo Courtesy of NIH 36 36

SLIDE 37

CONSIDERATIONS: CONSIDERATIONS: P i i D P i i D Prescription Drugs Prescription Drugs

Analgesics

Analgesics g g

Nonnarcotic

Nonnarcotic

Narcotic

Narcotic

General and Epidural

General and Epidural

Anti

Anti-

Infectives

Infectives

Antihistamines/

Antihistamines/ Decongestants Decongestants Decongestants Decongestants

Bronchodilators

Corticosteroids

Antihypertensives

Cardiac Drugs

37 37

SLIDE 38

CONSIDERATIONS: CONSIDERATIONS: Prescription Drugs Prescription Drugs

Anticoagulants

Anticoagulants g

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

Gastrointestinal Drugs

Gastrointestinal Drugs Gastrointestinal Drugs Gastrointestinal Drugs

Psychotherapeutic Drugs

Benzodiazepines

Antiepileptics

Radiopharmaceuticals

Miscellaneous Drugs

38 38

Miscellaneous Drugs

SLIDE 39

SSRIs SSRIs SSRIs SSRIs

1 Sertraline (Zoloft)

Sertraline (Zoloft)

1. 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

SLIDE 40

ADVERSE EFFECTS ADVERSE EFFECTS

(Overall Rate: 1%) (Overall Rate: 1%)

Psychotherapeutics (Antidepressants, Sedatives,

Psychotherapeutics (Antidepressants, Sedatives, Antipsychotics): 31% Antipsychotics): 31%

Antimicrobials: 17%

Anticonvulsants: 16%

Analgesics (NSAIDs, Opioids): 12%

Hormonal Drugs: 5%

Hormonal Drugs: 5% Iodides: 5% Iodides: 5%

Iodides: 5%

Cardiovascular Drugs: 4%

GIT Drugs: 2%

Antihistamines: 2%

Chemotherapeutics: 2%

40 40

SLIDE 41

ADVERSE EFFECTS ADVERSE EFFECTS ADVERSE EFFECTS ADVERSE EFFECTS

Psychotherapeutics (Antidepressants, Sedatives,

Psychotherapeutics (Antidepressants, Sedatives, Antipsychotics): Drowsiness Antipsychotics): Drowsiness

Antimicrobials: Diarrhea

Anticonvulsants: Drowsiness, sedation, poor feeding

Analgesics (NSAIDs, Opioids): Drowsiness, sedation

Hormonal Drugs: Decreased milk supply, volume,

Hormonal Drugs: Decreased milk supply, volume, quantity quantity quantity quantity

Iodides: Thyroid suppression

Cardiovascular Drugs: Weakness, hypotension,

Cardiovascular Drugs: Weakness, hypotension, bradycardia bradycardia bradycardia bradycardia

GIT Drugs: GIT upset

Antihistamines: Irritability, drowsiness

41 41

Chemotherapeutics: Toxic effects of treatment

SLIDE 42

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

SLIDE 43

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?

43 43

SLIDE 44

ABM Clinical Protocol #15 ABM Clinical 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

http: / / www.bfmed.org/ Resources/

http: / / www.bfmed.org/ Resources/ p / / g/ / p / / g/ / Protocols.aspx Protocols.aspx

44 44

SLIDE 45

CONSIDERATIONS: CONSIDERATIONS: OTC M di i OTC M di i OTC Medications OTC Medications

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

Cough and Cold Lozenges

Cough and Cold Lozenges and Sprays and Sprays

Nasal Preparations

Hemorrhoidal Preparations

Sleep Preparations

Stimulants

Stimulants A tit S t P d t A tit S t P d t p

Asthma Preparations

Antacids and Digestive Aids

Appetite Suppressant Products

Insulin Preparations

Artificial Sweeteners

Laxatives / Stool Softeners

Miscellaneous OTCs

45 45

SLIDE 46

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

SLIDE 47

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

SLIDE 48

CONSIDERATIONS: CONSIDERATIONS: H b l (M j G l ) H b l (M j G l ) Herbals (Major Galactogogues) Herbals (Major Galactogogues)

Chaste Tree

Fennel

Fennel Fenugreek Fenugreek

Fenugreek

Garlic

Goat's Rue

Milk Thistle / Blessed Thistle

48 48

SLIDE 49

CONSIDERATIONS: CONSIDERATIONS: H b l (Mi G l ) H b l (Mi G l ) Herbals (Minor Galactogogues) Herbals (Minor Galactogogues)

Anise

Marshmallow

Anise

Borage

Alfalfa

Marshmallow

Nettle

Hops

Alfalfa

Caraway

Coriander

Hops

Oat Straw

Red Clover

Coriander

Dandelion

Dandelion Dill Dill

Red Clover

Red Raspberry

Red Raspberry Vervain Vervain

Dill

Vervain

49 49

SLIDE 50

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 John’s Wort Valerian St John’s Wort Valerian

St. John s Wort, Valerian
St. John s 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

SLIDE 51

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 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 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

SLIDE 52

CONSIDERATIONS: CONSIDERATIONS: R i l D R i l D Recreational Drugs Recreational Drugs

Amphetamine / Methylphenidate

Amphetamine / Methylphenidate p y p p y p

Marijuana

Marijuana Cocaine Cocaine

Cocaine

Phencyclidine

Narcotics

Caffeine

Alcohol

Nicotine

52 52

Nicotine

SLIDE 53

RECREATIONAL DRUGS RECREATIONAL DRUGS RECREATIONAL DRUGS RECREATIONAL DRUGS

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

nly to the nursling but to the mother as
nly to the nursling but to the mother as
nly to the nursling, but to the mother as
nly to the nursling, but to the mother as

well. well.

53 53

SLIDE 54

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

SLIDE 55

Courtesy of NIH Courtesy of NIH 55 55

SLIDE 56

JAPhA Article JAPhA Article JAPhA Article JAPhA 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

SLIDE 57

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.

SLIDE 58

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

SLIDE 59

PUBLICATIONS PUBLICATIONS PUBLICATIONS PUBLICATIONS

Nice FJ DeEugenio D DiMino TA Freeny ice FJ DeEugenio D DiMino TA Freeny Nice 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

SLIDE 60

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 g 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

SLIDE 61

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

SLIDE 62

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

SLIDE 63

Thank you for your participation Thank you for your participation Thank you for your participation Thank you for your participation

63 63