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Introduction
Over the years, far too
many women have been wrongly told they had
to stop breastfeeding. The decision about
continuing breastfeeding when the mother
takes a drug, for example, is far more involved
than whether the baby will get any in the
milk. It also involves taking into consideration
the risks of not breastfeeding, for the
mother, the baby and the family, as well
as society. And there are plenty of risks
in not breastfeeding, so the question essentially
boils down to: Does the addition of a small
amount of medication to the mother’s
milk make breastfeeding more hazardous than
formula feeding? The answer is almost never.
Breastfeeding with a little drug in the
milk is almost always safer. In other words,
being careful means continuing breastfeeding,
not stopping.
Remember that stopping
breastfeeding for a week may result in permanent
weaning since the baby may then not take
the breast again. On the other hand, it
should be taken into consideration that
some babies may refuse to take the bottle
completely, so that the advice to stop is
not only wrong, but often impractical as
well. On top of that it is easy to advise
the mother to pump her milk while the baby
is not breastfeeding, but this is not always
easy in practice and the mother may end
up painfully engorged.
Breastfeeding and Maternal
Medication
Most drugs appear in the
milk, but usually only in tiny amounts.
Although a very few drugs may still cause
problems for infants even in tiny doses,
this is not the case for the vast majority.
Nursing mothers who are told they must stop
breastfeeding because of a certain drug
should ask the physician to make sure of
this by checking with reliable sources.
Note that the CPS (in Canada) and the PDR
(in the USA) are not reliable sources of
information about drugs and breastfeeding.
Or the mother should ask the physician to
prescribe an alternate medication that is
acceptable during breastfeeding. In this
day and age, it should not be a problem
to find a safe alternative. If the prescribing
physician is not flexible, the mother should
seek another opinion, but not stop breastfeeding.
Why do most drugs appear
in the milk in only small amounts? Because
what gets into the milk depends on the concentration
in the mother’s blood and the concentration
in the mother’s blood is often measured
in micro- or even nano-grams per millilitre
(millionths or billionths of a gram), whereas
the mother takes the drug in milligrams
(thousandths of grams) or even grams. Furthermore,
not all the drug in the mother’s blood
can get into the milk. Only the drug that
is not attached to protein in the mother’s
blood can get into the milk. Many drugs
are almost completely attached to protein
in the mother’s blood. Thus, the baby
is not getting amounts of drug similar to
the mother’s intake, but almost always,
much less on a weight basis. For example,
in one study with the antidepressant paroxetine
(Paxil), the mother got over 300 micrograms
per kg per day, whereas the baby got about
1 microgram per kg per day).
Most drugs are safe
if:
- They are commonly prescribed
for infants. The amount the baby would
get through the milk is much less than
he would get if given directly.
- They are considered
safe in pregnancy. This is not always
true, since during the pregnancy, the
mother’s body is helping the baby’s
get rid of drug. Thus it is theoretically
possible that toxic accumulation of the
drug might occur during breastfeeding
when it wouldn’t during pregnancy
(though this is probably rare). However,
if the concern is for the baby’s
merely getting exposed to a drug, say
an antidepressant, then the baby is getting
exposed to much more drug at a more sensitive
time during pregnancy than during breastfeeding.
Recent studies about withdrawal symptoms
in newborn babies exposed to SSRI type
antidepressants during pregnancy somehow
seems to implicate breastfeeding as if
this type of problem requires a mother
not to breastfeed. (Good example of how
breastfeeding is blamed for everything.)
In fact, you cannot prevent these withdrawal
symptoms in the baby by breastfeeding,
because the baby gets so little in the
milk..
- They are not absorbed
from the stomach or intestines. These
include many, but not all, drugs given
by injection. Examples are gentamicin
(and other drugs in this family of antibiotics),
heparin, interferon, local anaesthetics,
omperazole.
- They are not excreted
into the milk. Some drugs are just too
big to get into the milk. Examples are
heparin, interferon, insulin, infliximab
(Remicade), etanercept (Enbrel).
The following are a
few commonly used drugs considered safe
during breastfeeding:
- Acetaminophen (Tylenol,
Tempra), alcohol (in reasonable amounts),
aspirin (in usual doses, for short periods).
Most antiepileptic medications, most antihypertensive
medications, tetracycline, codeine, nonsteroidal
antiinflammatory medications (such as
ibuprofin), prednisone, thyroxin, propylthiourocil
(PTU), warfarin, tricyclic antidepressants,
sertraline (Zoloft), paroxetine (Paxil),
other antidepressants, metronidazole (Flagyl),
omperazole (Losec), Nix, Kwellada.
Note: Though generally
safe, fluoxetine (Prozac) has a very long
half life (stays in the body for a long
time). Thus, a baby born to a mother on
this drug during the pregnancy, will have
large amounts in his body, and even the
small amount added during breastfeeding
may result in significant accumulation and
side effects. These are rare, but have happened.
There are two options that you might consider:
1. Stop the fluoxetine
(Prozac) for the last 4 to 8 weeks of your
pregnancy. In this way, you will eliminate
the drug from your body and so will the
baby. Once the baby is born, he will be
free of drug and the small amounts in the
milk will not usually cause problems and
you can restart the fluoxetine (Prozac).
2. If it is not possible
to stop fluoxetine (Prozac) during your
pregnancy, consider changing to another
drug that does not get into the milk in
significant amounts once the baby is born.
Two good choices are sertraline (Zoloft)
and paroxetine (Paxil).
- Medications applied
to the skin, inhaled (for example, drugs
for asthma) or applied to the eyes or
nose are almost always safe for breastfeeding.
- Drugs for local or regional
anaesthesia are not absorbed from the
baby’s stomach and are safe. Drugs
for general anaesthesia will get into
the milk in only tiny amounts (like all
drugs) and are extremely unlikely to cause
any effects on your baby. They usually
have very short half lives and are eliminated
extremely rapidly from your body. You
can breastfeed as soon as you are awake
and up to it.
- Immunizations given
to the mother do not require her to stop
breastfeeding. On the contrary, the immunization
will help the baby develop immunity to
that immunization, if anything gets into
the milk. In fact, most of the time nothing
does get into the milk, except, possibly
some of the live virus immunizations,
such as German Measles. And that’s
good, not bad.
- X-rays and scans. Ordinary
X-rays do not require a mother to stop
breastfeeding even when used with contrast
material (example, intravenous pyelogram).
The reason is that the material does not
get into the milk, and even if it did
it would not be absorbed by the baby.
The same is true for CT scans and MRI
scans. You do not have to stop for even
a second.
What about radioactive
scans?
We do not want babies
to get radioactivity, but we rarely hesitate
to do radioactive scans on them. When a
mother gets a lung scan, or lymphangiogram
with radioactive material, or a bone scan,
it is usually done with technetium (though
other materials are possible). Technetium
has a half life (the length of time it takes
for ½ of all the drug to leave the
body) of 6 hours, which means that after
5 half lives it will be gone from the mother’s
body. Thus, 30 hours after injection all
of it will be gone and the mother can nurse
her baby without concern about his getting
radiation. But does all the radioactivity
need be gone? After 12 hours, 75% of the
technetium is gone, and the concentration
in the milk very low. I think that waiting
2 half lives is enough, for a material such
as technetium. But:: Not all technetium
scans require stopping breastfeeding at
all (HIDA scan, for example). It depends
on which molecule the technetium is attached
to. In the first few days, there is very
little milk (though there is enough). In
this situation it would be unnecessary for
the mother to stop breastfeeding after a
lung scan, for example. However, one of
the most common reasons to do a lung scan
is to diagnose a clot in the lung. This
can now be done better and faster with CT
scan, which does not require interrupting
breastfeeding for even 1 second.
If you decide that interruption
of breastfeeding is the best course to follow,
then express milk for several days in advance
(if you have advance warning about the test).
Only occasionally is a radioactive scan
so urgent that it cannot be delayed for
a few days.
Thyroid scans are different. Radioactive
iodine (I¹³¹) is concentrated
in milk and will be ingested by the baby
and it will go to his thyroid where it will
stay for a long time. This is definitely
of concern. So, the mother will have to
stop breastfeeding? No, because often the
test does not need to be done at all. Differentiating
postpartum thyroiditis from Graves’
Disease (the most common reason for doing
the scan in nursing mothers) does not require
a thyroid scan. Get more information from
the clinic. If a scan needs to be done,
it is possible to do a thyroid scan I¹²³,
which requires stopping for only 12 to 24
hours, depending on the dose given. Don’t
forget to express milk in advance so the
baby can get it instead of formula.
Questions? (416) 813-5757
(option 3) or drjacknewman@sympatico.ca
or my book Dr. Jack Newman’s Guide
to Breastfeeding (called The Ultimate Breastfeeding
Book of Answers in the USA)
Handout
#9a. You Should Continue Breastfeeding (1)
(Drugs and Breastfeeding). Revised January
2005
Written by Jack Newman, MD, FRCPC. ©
2005
This
handout may be copied and distributed without
further permission,
on the condition that it is not used in
any context in which the WHO code on the
marketing of breastmilk substitutes is violated
1. Breastfeeding:
Starting out right
a) The
importance of Skin-to-Skin contact
2. Colic in the Breastfed Baby
3. a) Sore Nipples
b) Treatments
for Sore Nipple and Sore Breasts
4. Is my baby getting enough?
5. Using a Lactation Aid
6. Using Gentian Violet
7. Breastfeeding and Jaundice
8. Finger Feeding
9. a) You should continue breastfeeding
(Medications and breastfeeding)
b) You
should continue breastfeeding (Illness in the mother or baby)
10. Breastfeeding and other foods
11. Some breastfeeding myths
12. More breastfeeding myths
13. Still more breastfeeding
myths
14. More and more breastfeeding
myths
15. Breast compression
16. Starting solid foods
17. What to feed the baby when
the mother is working outside the home
18. How to know a health professional
is not supportive of breastfeeding
19. a) Domperidone 1
b) Domperidone
2
20. Fluconazole
21. Breastfeed a toddler –
Why on earth?
22. Blocked ducts and
mastitis
23. Breastfeeding your adopted baby
24. Miscellaneous treatments for problems
25. Slow weight gain after
the first few months
26. When the Baby refuses to
latch on
27. Expressing Milk
28. Toxins and Infant Feeding
How breastmilk protects Newborns
Risks of formula feeding
Breastfeeding and guilt
Candida protocol
Protocol to increase the intake
of Breastmilk by the Baby ("Not enough milk")
When latching
Protocols for Induced Lactation
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