The Secret to Pain Free Breastfeeding

Breastfeeding Help And Baby Care For New Parents

The Breastfeeding Help Video Compilation By Australian International Board Certified Lactation Consultant Kate Hale is full of useful information about breastfeeding and how to manage low supply. It is very clear and concise in its content. It also has a lot handy tips for new mothers, including how to bath, massage and dress an infant. Learn how to care for a new-born, including how to deeply latch your baby and breastfeed without pain within minutes for a contented baby and an end to sore nipples. It is the only Dvd of which I am aware that is readily available to new mothers with an actual demonstration on how to correctly latch a baby on and off the breast using a couple of alternative feeding positions. Reading about breastfeeding in a book is nowhere near as useful as watching the Dvd. Read more...

Breastfeeding Help And Baby Care For New Parents Overview

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My Breastfeeding Help And Baby Care For New Parents Review

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The advantages of breastfeeding versus the risks of maternal medication

No discussion of the risks of maternal medications can be undertaken without an understanding of the benefits of being breastfed for the child. Advantages to breastfeeding have been recognized in general terms for decades. However, new information and evidence-based studies following breastfed infants for months and even years have identified many additional advantages and protections provided by human milk and the process of breastfeeding. There are many advantages to breastfeeding for the mother herself. The process facilitates the rapid recovery postpartum, with a reduccd loss of blood and the prompt involution of the uterus to its pre-pregnant state (Labbok 2001). Further breastfeeding prevents post-partal depression (Groer 2005), and reduces the long-term risk of obesity and osteoporosis for the nursing mother. Studies of specific diseases show that there is a reduced risk of breast cancer and ovarian cancer for women who breastfeed (Lawrence 2005, Collaborative Group 2002)....

Breastfeeding despite environmental contaminants

Persistent organochlorinc compounds are stored in the fatty tissue for life, and are only mobilized by losing weight and breastfeeding. For this reason, a low-calorie diet should be avoided while breastfeeding. Apart from a marked intake of animal fat and contaminated seafood (especially shellfish), the current dietary habits of the mother have little influence on the contamination levels in the milk. However, a primarily vegetarian diet of products having low pesticide residues does lead to a lower level of contaminants in the mother's milk. Every breastfed child reduces the contaminant load in the fatty tissue of the mother and in the milk by about 10-20 . It could be said, somewhat cynically, that breastfeeding is the most effective detoxification technique for the mother. There is speculation as to whether so-called endocrine disruptors, i.e. contaminants with estrogenic properties (some PCBs, dioxins, phthalates), taken in via the mother's milk, may impair an infant's development...

Breastfeeding and the workplace

The motto for the World Breastfeeding Week 2000 (Breastfeeding It's Your Right''), coined by the World Alliance for Breastfeeding Action (WABA), raised awareness that it is the responsibility of both political bodies and society at large to make it possible for women to breastfeed. Part of this responsibility is creating conditions that permit a mother to breastfeed for as long as she and her baby want to, despite her being employed outside the home. At the same time, the motto emphasized the right of the child to be nourished optimally - and that means the right to be breastfed. The revised International Labor Organization Convention (ILO Convention No. 183), passed in June 2000, codifies the mother's right to retain her job, protection from being dismissed, and the adaptation of both the work and the working hours to suit the situation of the pregnant or breastfeeding mother. Some countries have gone beyond the convention and passed legislation which provides that pregnant or...

Secondgeneration Effects

A 37-year-old woman with severe bipolar disorder, who continued to take lithium throughout pregnancy, had a normal delivery but was not allowed to breast-feed (75A). In a review of the use of psychotropic drugs during breast-feeding it was briefly mentioned that lithium was not advisable but was justified under certain circumstances (76r). Lithium was also briefly discussed in a review of xenobiotics and breast-feeding (77r ).

Desogestrel Cerazette

Or after childbirth as of the 21st day, if the woman does not breastfeed - Breast-feeding it is recommended to wait 6 weeks after childbirth before starting desogestrel in breastfeeding women. However, if it is the only contraceptive method available or acceptable, it can be started 3 weeks after childbirth.

Second Generation Effects Pregnancy

Ciclosporin is excreted into human breast milk and because of potential immunosuppression, breastfeeding is usually regarded as contraindicated. Reassuring reports are now however available (SEDA-21, 385). After follow-up for 12-36 months in seven breast-fed infants (duration 4-12 months) whose mothers were treated with ciclosporin, none of them experienced renal or other long-term adverse

Motor and physical development

Other symptoms such as sneezing, discoloration of the skin, and fever. Such infants may suck frantically on their hands or thumbs and may have trouble breast-feeding because of an uncoordinated sucking reflex. Infants undergoing neonatal abstinence can develop tremors and become extremely irritable. Neonatal abstinence is a form of withdrawal experienced by infants who have been exposed to heroin. If the condition is treated immediately it typically has no long-term negative effects.

Cognitive development

In 2001, the American Academy of Pediatrics (AAP) put marijuana on its list of drugs that adversely affect infants during breast-feeding. According to the AAP, the active ingredient in marijuana, THC, can be stored in a mother's tissues for several weeks or months and accumulates with continued use. Thomas Hale, author of the book Medications and Mother's Milk, reports that breast milk produced by chronic, heavy marijuana users shows extremely high concentrations of THC. Marijuana taken into the body through breast-feeding can cause sleepiness in the baby, which may lead to slow weight gain and possibly slow overall development. The study also found that babies whose mothers smoke marijuana regularly have a higher risk of dying from Sudden Infant Death Syndrome, or SIDS.

General adverse effects

Vitamin B12 deficiency most frequently is seen in people over 60 years of age (11). Deficiency of vitamin B12 in younger adults is rare, but can occur as a result of reduced absorption of vitamin B12, for example in pernicious anemia, atrophic gastritis type B, long-term use of blockers of acid secretion, or short bowel syndrome after resection of the terminal ileum (18,19). Vitamin B12 deficiency in children usually depends on inborn defects of vitamin B12 metabolism or on insufficient support during pregnancy and breastfeeding.

Second Generation Effects Fertility

In an 8-year follow-up of Swedish children whose mothers used combined oral contraceptives while breastfeeding, there were no negative effects on health, growth, or development (294). It should be realized that the hormonal content of natural human milk and cows' milk is not negligible. If hormonal contraception is to be used during lactation, it would be sensible to prefer low-

Pregnancy Category D

The drug has been given to mice, rats, and rabbits at 5 to 32 times the normal human dose without producing birth defects. Researchers conducting one experiment concluded, however, that the drug altered behavior of mice after fetal exposure (making males more uneasy and females less uneasy) while slowing their development. Tests indicate that the drug will pass from a pregnant woman into the fetus. The substance has been successfully used to treat eclampsia, a serious disease of late pregnancy involving convulsions, but midazolam is generally not desirable for pregnant women. The drug passes into the milk supply of nursing mothers, and caution is recommended about breast-feeding in such circumstances.

Toxicity of medications in the mothers milk

Of a group of 838 mothers who had drug therapy while breastfeeding, about 11 reported symptoms in their infants that were possibly caused by the medication. In no case did this involve serious symptoms needing therapeutic intervention. The following associations were observed by the mothers (Ito 1993 B) In some cases, an interruption of breastfeeding following the administration of medication may make sense. This may be easier to adhere to if the mother chooses, for instance, to take the medication in the evening after the last breastfeed. By avoiding the peak plasma times, the maternal drug levels that reach the milk can be minimized. In the case of paracetamol, it was even demonstrated that there was a higher concentration of medication if the breast had been frequently pumped (Notarianni 1987). The following exposures are known to be problematic in breastfeeding When administration cannot be avoided in an individual case, it must be decided whether to abandon breastfeeding...

Medications that affect lactation

Medications with an antidopamine effect, such as phenothiazine, haloperidol, and other neuroleptics, such as sulpiride and risperidone, as well as the antihypertensive a-methyldopa, and medications used to stimulate intestinal peristalsis, domperidone and metoclopramide, can, as a result of increasing the secretion of prolactin, stimulate milk production. The sympatholytic action of reserpine can have the same effect. Growth hormone and thyrotrophin-releasing hormone can also enhance milk production. Domperidone and metoclopramide are occasionally used for this purpose - for example. 10 mg metoclopramid three times a day (for a maximum of 7-10 days) and then tapering off the dosage for 2-5 days is sometimes recommended. Domperidone (not available in the USA) is less capable of crossing the blood-brain barrier, and therefore the risk of extrapyramidal symptoms is remote. Due to a molecular mass of 426, protein binding > 90 , and poor oral bioavailability, the relative dose for a...

Classic nonsteroid antiinflammatory drugs

Among the nonsteroid antirheumatics, the acidic antiphlogistics ibuprofen and flurbiprofen are the drugs of choice during breastfeeding. Occasional use of azapropazon, diclofenac, and flufenamic acid is also permissible. Accidental administration of one of the other nonsteroid antirheumatics does not require any limitation of breastfeeding, although the medication should be changed.

Other features of the patient

In patients with reduced respiratory reserve, such as those with emphysema, severe obesity, cor pulmonale, and kyphoscoliosis, opioids must be used with caution. The relative benefits and harms of using opioids in patients taking monoamine oxidase inhibitors, those with a history of drug abuse, asthma, hepatic impairment, hypotension, raised intracranial pressure, or head injury, and during pregnancy or breast feeding, should be carefully considered. Dextropropoxyphene, pethidine, and methadone should be used with caution (SEDA-21, 85).

Anticholinergics for asthma treatment

The anticholinergic effect of ipratropium bromide and oxitropium bromide also causes bronchodilatation and can lead to a considerable reduction in the necessary -sympathomimetic dosage. Documented experience on its use during breastfeeding is limited. However, good tolerance can be assumed with the well-tried ipratropium bromide. Recommendation. Ipratropium bromide is acceptable for treating asthma while breastfeeding, and should be used in preference to oxitropium bromide.

Agents used for chronic inflammatory bowel diseases

Mesalazine consists of 5-aminosalicylic acid, the anti-inflammatory portion of sulfasalazine. With a daily intake of 1500mg, 0.015 mg kg daily was calculated for the infant. This is less than 0.1 of the maternal weight-related dosage (Klotz 1993, Jenss 1990). However, taking into consideration the metabolite, acetyl-5-aminosaIicylic acid (about 12 mg 1 of milk), it would be 7.5 , A further publication also reports 15 mg active ingredient per liter (Christensen 1994). Silverman (2005) found very low levels of 5-aminosalicylic acid in the milk of four lactating mothers however, the content of the relatively inactive metabolite N-acetyl-5-aminosalicylic acid was 1000-fold higher. A case report described an infant who developed diarrhea following repeated rectal administration of mesalazine to his mother. The diarrhea ceased when therapy was ended (Nelis 1989). In a further group of eight breastfeeding women, there was also a report of a child with diarrhea (Ito 1993). However, the...

General Information

Spermicides, especially in certain communities, have important advantages over the more modern methods of contraception they are immediately reversible, are available over the counter without prescription, can be used by breastfeeding women, and are under direct female control.

Penicillins cephalosporins and other f3lactam antibiotics

In the case of aztreonam, a 0,2 relative dosage was reported for the baby in the next breastfeed after the mother had taken a single dose (Ito 1990), Recommendation. Penicillin derivatives and cephalosporins are the antibiotics of choice during breastfeeding. As far as possible, substances that have been in use for a long time (e.g. second-generation cephalosporins) are preferable. When necessary, other -(-lactam antibiotics and davulanic acid can also be used.

Erythromycin and other macrolides

There are no reports of specific intolerance during breastfeeding to any of the macrolides mentioned here. This also applies to josamycin. Recommendation. In addition to penicillin derivatives and cephalosporins, erythromycin and roxithromycin are the antibiotics of choice during breastfeeding, The macrolidic antibiotics, azithromycin, clarithromycin, josamycin, and spiramycin, are second-choice medications. Where there is already a noteworthy icterus in the first days of life, caution should be exercised if the mother receives high dosages of parenteral macrolides.

Other antibiotics and urinary tract antiseptics

With clindamycin, a maximum of 3.1 mg 1 milk was measured. For the infant, this represents about 6 of the maternal weight-related dosage, or 15 of the daily dosage for an infant. In a case report, hemorrhagic enteritis was described in an infant whose mother had taken clindamycin and gentamicin. The symptoms improved spontaneously after breastfeeding was interrupted (survey by Bennett 1996). There are no data on the use of colistin and polymyxin B during breastfeeding. Recommendation. When it is unavoidable, clindamycin, vancomycin, and lincomycin, as well as colistin and polymyxin B, may be prescribed. However, clindamycin should not be routinely used after dental procedures. Chloramphenicol is contraindicated. Generally, an antibiotic with a lower risk potential can easily be substituted for it. Administration of a single dose does not require any limitation of breastfeeding. This also applies following short-term usage of the urinary tract antiseptic discussed.

Aminoglycoside antibiotics

When aminoglycosides are strongly indicated, they may be used during breastfeeding. Restricted use is particularly applicable to the early postnatal period, since both quantitative absorption and accumulation by the infant must be reckoned with and, at least in the case of streptomycin, an ototoxic effect cannot be ruled out.

Maternal immunization

A woman who has not received all the recommended immunizations before or during pregnancy may be immunized in the postpartum period even though she is breastfeeding. The presence of live viruses in the milk does not present a problem because the viruses have been attenuated. According to the statement of the American Academy of Pediatrics Committee on Infectious Diseases (2006), breastfeeding women may be immunized with both killed and live vaccines. All vaccines and immunoglobulins used for mothers are considered safe for the infant during breastfeeding. Lactating women can be

Calcium antagonists

With nifedipine and its active pyridine metabolites, a maximum of 2-10 ig kg daily is transmitted to the infant when the mother takes 30-90 mg a day. That is less than 5 of a weight-related child's dose. Average values of 2 and less are probably even more realistic (Murray 1992, Manninen 1991, Ehrenkranz 1989, Penny 1989). Nifedipin is also used successfully to treat Raynaud phenomenon of the breast nipple. Anderson (2004) reports on 12 breastfeeding women complaining of pain in the nipple, which was finally diagnosed as Raynaud phenomenon. Those choosing nifedipin therapy instantly improved. Of the 12 women, 8 had been treated with antimycotics previously because of suspected mycosis. Recommendation. Diltiazem, nifedipine, nitrendipine, and verapamil are the calcium antagonists of choice during breastfeeding. The results with nicardipine and nimodipine do not suggest any risk. Individual doses of other calcium antagonists do not require limitation of breastfeeding, but therapy should...

Recommendations classical anticonvulsants

Monotherapy with phenytoin, valproate or carbamazepine is compatible with breastfeeding. With carbamazepine, however, the baby should be observed for symptoms such as weak suck, vomiting, and tiredness. If these symptoms occur, the concentration of carbamazepine in the infant's serum should be measured. In suspicious cases, liver values should also be measured. Antiepileptic therapy with the barbiturates, clonazepam and ethosuximide should be considered problematic during breastfeeding. If treatment is unavoidable, the decision to breastfeed should be made individually, and the infant should be observed for symptoms such as weak suck, vomiting, and tiredness. Where there is a suspicion of side effects, the concentration in the infant's serum should be determined and a decision taken regarding whether formula should be added to reduce drug transfer via mother's milk, or the baby should be weaned. Anticonvulsive combination therapy with barbiturates, clonazepam or...

Selective serotonin reuptake inhibitors

Escitalopram is an active isomer of citalopram with a molecular mass of 414. At 56 , the protein binding is lower than that of citalopram (80 ) and could facilitate a transfer to the milk. Data are insufficient with respect to lactation. A case report describes a child aged 3 weeks, whose weight gain was insufficient from the beginning of the maternal therapy and up to the age of 4 months. In addition, slightly elevated liver enzymes, moderate muscle hypertonia of the upper extremities, irritability, and frequent crying were observed. The symptoms resolved after adding formula feeding in the fifth month (Mcrlob 2005). A similar observation was documented by the current author and colleagues. A hyperirritable newborn started high-pitched crying 2 hours after breastfeeding (5-6 hours after escitalopram intake by the mother), every afternoon. When the mother took her tablet in the morning instead, her child's symptoms appeared at the same time interval after breastfeeding. After adding...

Atypical neuroleptics

Olanzapine has a rather long half-life of up to 54 hours. Based on the data of seven mother-child pairs, the median infant dose of olanzapine ingested via milk was 1 of the maternal dose the median milk plasma ratio was 0.4 for the six patients with data collected over the dose interval. Corresponding values in the patient with single-point data were 1.1 and 0.8. Olanzapine was not detected in the plasma of the six infants with an evaluable plasma sample. All the infants were healthy and experienced no side effects (Gardiner 2003). In another child whose mother has already been treated during pregnancy with lOmg d, after delivery the plasma level of olanzapine in the infant was one-third of the maternal plasma level, and during breastfeeding it decreased to an undetectable limit (Kirchheiner 2000). In a study with five mother-child pairs, the median relative infant dose was 1.6 (range 0-2.5 ) of the weight-adjusted maternal dose. During the study period, there were no apparent ill...

Immunosuppressive and immune antineoplastic agents

Cyclosporins use in lactating women has been reported in several studies. Levels in maternal plasma studied in 15 mother-child pairs (Moretti 2003, Munoz-Flores-Thiagarajan 2001, Merlob 2000, Nyberg 1998. Thiru 1997) varied from 55 to 903 ng ml. Corresponding milk levels were 14-1016 ng ml. which works out at (at maximum) 2 of the weight-adjusted maternal dose. In another case, where the mother received 3 mg kg per day, milk levels averaged 596 ig l but infant trough blood levels remained under 3ng l when mother's were 260 ng 1. In a series of five patients receiving cyclosporine. however, one clinically unremarkable infant had trough blood levels (131 jig 1) near therapeutic levels (Moretti 2003). The other four infants had levels below 25pg l. Another 17 unremarkable breastfed infants were reported by Armenti (2003). The peak time for maternal blood level is 3.5 hours post-dose, so this would mean not breastfeeding for at least 4 hours to avoid peak milk levels. It is poorly...

Thyroid hormones and thyroid receptor antibodies

Thyroid receptor antibodies (TRAb) can result in transient neonatal thyroid disease by transfer through milk from mothers treated for thyrotoxicosis, Serum TRAb concentration in neonates decrease continuously with time after birth. The calculated half-life for offspring-serum and breast-milk TRAb was calculated as approximately 3 weeks and 2 months, respectively. Transient neonatal thyroid disease may be worse and more prolonged during breastfeeding as a consequence of TRAb in breast milk (Tbrnhage 2006). Recommendation. Substitution of thyroid and parathyroid hormones establishes a physiological state, and, thus should be continued during breastfeeding if necessary. Thyroid hormones should not be given together with thyrostatics, because higher dosages of thyrostatics would then be necessary.

Cyproterone acetate and other sexhormone inhibitors

Other antiandrogens, such as bicalutamide and flutamide, and antiestrogen-acting substances, such as aminoglutethimide, anas-trozole, formestan, raloxifene, and tamoxifen, as well as the sexhormone inhibitors danazol and tibolone, have practically no role during breastfeeding and have also not been studied. There are also no data on clomiphene and the progesterone antagonist mifepristone. In so far as its (accidental) use during breastfeeding happens at all, a toxic effect on the infant should not be expected due to the brief exposure. Recommendation. Antiandrogens and antiestrogens are contraindi-cated during breastfeeding. Accidental intake of a single dose does not require an Interruption of breastfeeding. However, treatment should not be continued.

Treatments for acne and psoriasis

Minocycline, now available in an extended-release oral preparation (Saladyn), is effective in moderate to severe acne (Shalita 2006). The extended-release form reduces the incidence of vestibular side effects and allows the lowest possible effective close (1 mg kg). Minocycline is a broad-spectrum tetracycline antibiotic capable of causing dental staining and reduced bone growth in children, though. It binds to milk calcium and is more effectively absorbed than previous tetracyclines. In the short term (less than 2 weeks) it is probably tolerable, but chronic use would be contraindicated during lactation. Minocycline has been measured in human milk, although it was not found in the plasma of breastfeeding infants whose mothers took 500 mg orally four times a day. For other anti-infectives, see Chapter 4.4. Recommendation. Systemic therapy with retinoids should not be undertaken during breastfeeding because of the toxic potential and the long halflife. This also applies to external use...

Vitamins minerals and trace elements

Vitamins, minerals, and trace elements can and should be used when the mother has real deficiencies. This also applies to iron and to vitamin D preparations. Such usage - and this also applies to fluoride for dental prophylaxis (Koparal 2000) - does not require lowering the infant's dosage in cases where he or she is also being treated directly, However, routine prescription of vitamin and mineral preparations during breastfeeding is not necessary if nutrition is balanced. In the interest of the future diet of the child who is still being breastfed, the mother should be made aware of the special importance of healthy nutrition, which, in the long run, can prevent the need for both her and her child to take not only substitutes but also therapeutic tablets. For iodine, see Chapter 4.11. Postpartum hair loss, which is frequently bemoaned and can be observed for many months, is physiologic and almost always improves spontaneously. The effectiveness of using mineral...

Promoting an Optimal Response to Therapy

When administering oxytocin intranasally to facilitate the letdown of milk, the nurse places the patient in an upright position, and with the squeeze bottle held upright, administers the prescribed number of sprays to one or both nostrils. The patient then waits 2 to 3 minutes before breastfeeding the infant or pumping the breasts. If a breast pump is being used, the nurse records the amount of milk pumped from the breasts. The nurse notifies the primary health care provider if milk drips from the breast before or after breastfeeding or if milk drips from the opposite breast during breastfeeding because there would be no need to continue drug therapy. The primary health care provider is notified if nasal irritation, palpations, or uterine cramping occurs.

Hormones and hormone antagonists

There are only a few publications that discuss tolerance of hypothalamic and pituitary hormones during breastfeeding. There are no data on the use during breastfeeding of the other hypothalamic and pituitary hormones, or their synthetic analogs cor-ticorelin, sermorelin, somatorelin, cetrorelix, chorionic gonadotrophin, gottadorelin, goserelin, leuprolide acetate, menotropin, nafarelin, trip-torelin, urogonadotropin, octreotide, somatostatin, tetracosactid, somatropin (growth hormone), follitrophin-a, follitrophin-3, urofol-litrophin, argipressin, lypressin, ornipressin, lanreotide, and terli pressin. This also holds true for the oxytocin-antagonist atosiban and the somatropin-receptor antagonist pegvisomant. Recommendation. With the exception of oxytocin, hypothalamic and pituitary hormones are seldom indicated during breastfeeding. No toxic effect on the infant has been demonstrated as yet, nor, due to its limited oral bioavailability, is this to be expected. Usage for appropriate...

H2receptor blockers and other ulcer therapeutics

H2-blockers may be given during lactation. Those with low concentration in breast milk should be preferred - for example, famotidine or nizatidine. If proton-pump blockers are indicated, omeprazole or pantoprazole should be chosen. Single doses of other medications do not require any limitation of breastfeeding, but a change in therapy is desirable.

Phenothiazine and thioxanthene neuroleptics

Regarding therapy during breastfeeding. In none of these reports, which have been published over a period of 40 years, is there any mention of serious or permanent effects on the child breastfed while his mother was being treated with this group of drugs (McElhatton 1992). The American Academy of Pediatrics considers phenoth-iazines compatible with breastfeeding because only very limited concentrations have been found in all the mothers' milk samples measured up to now, due to the high plasma protein binding. At the same time, however, it has been pointed out that long-term effects cannot be judged definitively. This, of coursc, also applies to all the other drugs with a central nervous system action. There was speculation recently that sudden infant death syndrome (SIDS) and sleep apnea could be induced by phenothiazines. Atypical neuroleptics were discussed as a therapeutic alternative (Hale 2004). Chlorpromazine, with a half-life of 30 hours, is absorbed at a very individual rate...

Estrogens gestagens and hormonal contraceptives

The amount of milk produced can decrease as a result of the influence of estrogen. With the older, higher-dosage contraceptives, a reduction of up to 40 was described. Changes in the caloric, protein, nitrogen, and lipid content were also observed, and arc apparently dependent on the starting point. With normally nourished women, the alterations slay within the physiological bounds. However, when there is a prior milk-supply problem, the influence on the milk production can be unfortunate when the mother is poorly nourished, it can be dramatic. In follow-up studies, including those on the new low-dosage preparations, the slight reductions observed in the average length of breastfeeding and in milk production, as well as the temporarily slightly reduced weight gain of the infants, did not have any effect on the physical or cognitive development (survey in Bennett 1996). Gestagens (norethisterone, levonorgestrel, medroxyprogesterone) as an ingredient of a mini- or combination pill or as...

Anticholinergic spasmolytics

Atropine-Wke preparations are considered to be contraindicated due to tbe extreme sensitivity of the infant to this group of substances. However, there have been no publications, as yet, in which negative effects on the baby have been described as a result of giving atropine-like drugs to a breastfeeding mother. Experience with other anticholinergics such as butinolin, denaverin, glycopyrrolate bromide, hymecromon, mebeverine, methanthelinium, oxybutynin, phenamazide, pipenzolate, pipoxolan, tiropramide, toltero-dine, trospium chloride, and valethamate bromide is insufficient with respect to breastfeeding. Recommendation. Butylscopolamine may be administered for appropriate indications. In the case of bladder incontinence, oxybutynin, which is equally widely used, also seems to be acceptable. Single administration of the other drugs mentioned does not require any limitation of breastfeeding. However, a critical look at the Indications, and in some cases a change in therapy, should be...

Antihistamines Hrblockers

In connection with the use of brompheniramine plus d-isoephedrine during breastfeeding, a hyperexcitable infant was described (Mortimer 1977). There are no published data on the passage of cetirizine into mother's milk, but the experience to date indicates no noteworthy symptoms during breastfeeding. The half-life of 9 hours is quite short, and the medication has scarcely any sedative or atropine-like action. There are, as yet, no data available on dimetindene during breastfeeding. This common H -blocker has a short half-life of 5-7 hours, and there are recommended doses for children beginning at 1 year. Dimetindene has relatively little sedative action, but has an atropine-like effect that should not be overlooked. Diphenhydramine was recommended by the American Academy of Pediatrics for the breastfeeding period. However, because of the strong sedative effect, its use as an antiallergic can no longer be justified. This also applies to doxylamine. There is no information on...

Other antidepressants

There are either no or insufficient data on the use of amineptine, amoxapine, atomoxetine, duloxetine, iprindole, medifoxamine, oxitrip-tan, reboxetine, tranylcypromine, I,-tryptophan, and viloxazine during breastfeeding. Recommendation. Due to the quantity and the results of documented experience, St. John's wort or hypericin preparations and mirtazapine are acceptable during breastfeeding, If compellingly indicated, moclobemid, venlafaxine, and bupropion are also tolerable. Whenever possible, the drugs of choice among tricyclic antidepressants or SSRIs are preferable. In general, monotherapy should be the goal. In cases of symptoms potentially associated with the drug therapy, a pediatrician and a teratology information center should be contacted to decide individually upon measuring drug values in the infant's serum, supplementary formula feeding, weaning, and or changing the therapy. As with all psychoactive drugs, there is insufficient experience on the long-term effects on...

Acyclovir antiretroviral drugs and other virustatics

No statements regarding kinetics or tolerance during breastfeeding can be made for the other virustatics, adefovir, amantadine, atazanavir, brivudine, cidofovir, famciclovir, fosatnprenavir, sodium foscarnet, ganciclovir, ribavirin, valaciclovir, and zanamivir, nor for the antiretroviral substances abacavir, delavirdin, didanosine, efavirenz, indinavir, lopinavir, nelfinavir, ritonavir, saquinavir, stavudine, tipranavir, and zalcitabine. Recommendation. Breastfeeding may continue when acyclovir or valaciclovir are administered externally or systemically. The other virustatics and antiretroviral substances, if really indicated, require an individual decision about continuing breastfeeding. In the case of drugs developed for HIV infection, an additional consideration is the risk of virus transmission via the mother's milk (see Chapter 4.15) here, guidelines only clearly recommend exclusive breastfeeding in those regions where lack of clean water for preparing infant formula and feeding...

Ethinylestradiollevonorgestrel Microgynon 30 Minidril

- Start the first day of menstruation or immediately after abortion or as of the 21st day after childbirth, if the woman does not breastfeed. - Breast-feeding contra-indicated before 6 weeks not recommended between 6 weeks and 6 months (except if it is the only available or acceptable contraceptive method) no contra-indication after 6 months.

Chenodeoxycholic acid and ursodeoxycholic acid

There is no documented experience on the tolerance of chenodeoxycholic acid and ursodeoxycholic acid during breastfeeding. Only limited amounts of ursodeoxycholic acid appear in the blood circulation, where they are overwhelmingly bound to albumin. Thus, a quantitative transfer into the milk is unlikely. Recommendation. Chenodeoxycholic acid and ursodeoxycholic acid should not be used while breastfeeding. The exception is therapy for primary biliary cirrhosis with ursodeoxycholic acid. In such a case, breastfeeding does not necessarily need to be limited.

Pyrazolone and phenylbutazone derivatives

There is very little experience of using these medications during breastfeeding. Taking its four main metabolites into consideration, an M P ratio of about 1 was calculated for metamizol. In one case, very similar serum concentrations were found in both mother and child (Zylber-Katz 1986). Another report describes cyanotic attacks in an infant after his mother took metamizol (Rizzoni 1984). Phenylbutazone has a half-life of 30-170 hours and an M P ratio of 0.1-0.3. There have been no toxic effects reported, as yet, in breastfed infants. The American Academy of Pediatrics does not object to its occasional use during breastfeeding. Recommendation. Famprofazone, kebuzone, metamizol, mofebutazone, phenazone, phenylbutazone, and propyphenazone should be avoided. Accidental intake does not require any limitations on breastfeeding, but the medication should be changed. Ibuprofen and paracetamol are the anal-gesics antiphlogistlcs of choice.

Eye ear and nose drops

The safest therapy for an acute upper respiratory infection (URI or cold) is not with systemic vasoconstrictors or decongestants, which can decrease milk production, but with local treatment. Nose drops which shrink mucous membranes (pseudoephedrine) are given in small doses and provide relief locally, and do not interrupt breastfeeding. Recommendation. Medication by drops in the eye, ear, and nose are usually compatible with breastfeeding. Ophthalmic atropine can be an issue if used chronically, as it may decrease milk production. Preparations for the eyes or ears that contain chloramphenicol, quinolines, and streptomycin should be avoided.

North American Teratology Information Services collaborating in the Organisation of Teratogen Information Specialists

Tel. (905) 521 2100 ext. 76788 serves Ontario open M-F 8-4 EST accepts calls from health carc providers by referral only. Does not handle breastfeeding. Tel. (800) 322 5014 or (781) 466 8474 serves Massachusetts and surrounding areas open M-F 9-4 EST accepts calls from both public and health care providers. Does not handle breastfeeding. Tel. (800) 532 6302 serves North Carolina only open M-F 8 30-4 30 EST accepts calls from both public and health care providers. Does not handle breastfeeding. Tel. (585) 275 3638 serves New York only open M-F 8-4 EST accepts calls from both public and health care providers. Does not handle breastfeeding.

Alley weed Colloquial term for marijuana Alliance for Cannabis Therapeutics

ACT, American organisation of induviduals who wants to end the restrictions against medical use of cannabis. Allilprodina Allylprodine. Allimentary orgasm Psychoanalytical term coined by Sandor Rado for the peak of gratification and allevation of tension experienced by infants during breast-feeding. This is, according to his theory, a prototype for the adult sexual orgasm, and the desire to recapture this early experience may lead to alcoholism and drug abuse.

Bromocriptine and other prolactin inhibitors

The effect of breastfeeding on the growth of the prolactinoma appears to be more limited than that of the pregnancy, so an interruption of dopamine agonist treatment with bromocriptine during breastfeeding can be considered (Rau 1996). Cabergoline is taken less often (e.g. once a week) because of its considerably longer half-life and period of effectiveness. In addition. there seem to be fewer side effects. With respect to the other prolactin inhibitors, lisuride, metergoline, and qiunagolide, experience during breastfeeding is insufficient. Recommendation, Because of maternal risks, routine prescription of bromocriptine to stop lactation is not indicated. If physical measures (and, in cases of mastitis, antibiotic treatment) are insufficient cabergoline should be preferred (see also Chapter 3.7). If therapy with prolactin inhibitors for mastitis is unavoidable, the briefest and lowest dosage should be used so that milk production will not diminish. As long as milk is being produced,...

Possible mechanisms for effects on brain morphology

Of interest here also would be the possible effects of marijuana on sexual differentiation of the brain. It has been demonstrated that there are sexually dimorphic structural differences in normal human brain (e.g. Schlaepfer et al., 1995). It is generally recognized that normal brain development follows a different course depending on sex (e.g. Hoffman and Swabb, 1991 Witelson, 1991). Sexual differences in brain organization are dependent on hormone levels occurring at critical periods. Prenatal exposure to marijuana administered to female rats has been shown to alter gonadal function (Nahas, 1984). Studies show the testes actively produce hormones beginning in utero (Huhtaniemi, 1989), and marijuana has been reported to decrease plasma levels of testosterone (Nahas, 1984). Marijuana has been shown to have significant effects on weight (smaller), height (shorter) and head circumference (smaller) of newborns to mothers' who used it during pregnancy and while breast feeding...

Circulatory drugs and vasodilators

There is no information on the passage into the milk of buflomedil, gingko biloba, and other drugs which are said to promote circulation. On the other hand, we have observed no toxic symptoms in the infant as a result of ginglto biloba - a medication that is not infrequently also used during breastfeeding. sosorbide mononitrates, isosorbide dinitrate, and glyceryl trinitrate have been insufficiently studied with respect to breastfeeding. The short half-lives and the usually brief use argue against a toxic risk for the breastfed infant.

Recommendations newer antiepileptics

As monotherapy, new antiepileptics are compatible with breastfeeding. However, close observation of the infant is recommended regarding drugs where there has been little experience or where substantial transfer has been documented. If there are any symptoms that could be associated with maternal drug therapy, the serum concentration in the child should be measured. To limit exposure, it may be necessary to supplement with formula or cease breastfeeding. In cases of prematurity, other risks and or antiepileptic combination therapy, an individual decision on breastfeeding must be taken.

Vitamin K antagonists coumarin derivatives and indanediones

During treatment with the oral anticoagulants acenocoumarol, phenprocoumon, and warfarin, breastfeeding may continue. To be on the safe side, the infant should receive 1 mg vitamin K orally, two to three times a week, in the first 4 weeks of life. To avoid any possible complications, the coagulation status should be determined after about 10-14 days, at least with premature infants. Flulndone and phenidone are contraindicated.

Amount of medication in the milk and relative dose

Sometimes there is also information about how much medication a child takes in with each meal. This method of calculating can make sense in the case of a single dosage of a drug with a short half-life. Based on the assumption of five breastfeeds a day, a child would drink 150 5 30 ml kg per breastfeed ( 0.031 kg per breastfeed). (50 ig l x 0.15 I kg daily) 5 1.5 ig kg per breastfeed.

Vein therapeutics and other local therapeutics

Hemorrhoid medications commonly contain local analgesics or anesthetics, and anti-inflammatory agents. To relieve local pain, lido-caine 1-2 is often used. Lidocaine has been measured in human milk, where it is calculated to be 40 of the maternal plasma level. When lidocaine was given intravenously for maternal ventricular arrhythmia, the breastfeeding infant received an estimated 2mg day. Lidocaine is poorly absorbed orally (35 ), so little would be absorbed via the milk. Thus the local use of preparation by the lactating women would have negligible effect on the infant (Giuliani 2001). When used for dental block and other local procedures, the dose is usually less than a total of 40 mg. On the other hand, the dose used for local liposuction is quite large. Genital or veneral warts are condylomata acuminata caused by the human papilloma virus (HPV) of several types, especially 6 and 11. Treatment is usually by electrocautery, laser, cryotherapy, or surgical excision. Chemical...

Dapsone nitrofurantoin and other drugs for urinary tract infections

Cotrimoxazole or trimethoprim alone (which is mostly just as effective as cotrimoxazole as monotherapy for urinary tract infections) can be used for appropriate indications. If actually indicated, nitrofurantoin and sulfonamides can also be prescribed. In the case of necessary treatment with dapsone, an individual decision must be made about limiting breastfeeding.

Second Generation Effects Teratogenicity

The benefit harm balance of breast-feeding during anti-depressant treatment is difficult to compute and must be done on an individual basis. In general, breast-feeding with SSRIs is regarded as safe, as the amount of drug ingested by the infant is very low. However, adverse effects in the child are reported occasionally (SEDA-25, 15) and it is difficult to exclude completely the possibility of long-term effects on brain development in the infant. Clearly, the lower the concentration of SSRI in the infant the less likely are problems of acute and longer-term toxicity. In two cases treatment of breast-feeding mothers with fluvoxamine (300 mg day) was associated with undetectable concentrations of fluvoxamine (below 2.5 ng ml) in the plasma of both infants (61). These results are encouraging, but further data will be needed before it can be concluded that fluvoxamine has an advantage over other SSRIs in this respect. Because fluoxetine has a long half-life it may be advisable not to use...

Acetylcysteine and other mucolytics

Acetylcysteine, ambroxol, and bromhexine are widely used and well-tolerated during breastfeeding. There are no details available on their kinetics. Carbocisteine, guaiacol, guaifenesin, mesna, and preparations with essential oils such as cineol, myrtle, lime, and eucalyptus are probably also well-tolerated during breastfeeding, but here too there are no systematic studies to date. Essential oils can change the taste of the milk and lead to feeding problems. Recommendation. Acetylcysteine, ambroxol, and bromhexine are the mucolytics of choice during breastfeeding when non-drug procedures such as abundant fluid and inhalation are not really effective. Carbocisteine, guaiacol, guaifenesin, and mesna should be avoided. Potassium iodate as an expectorant is absolutely contraindicated during breastfeeding.

Methylergometrine methylergonovine

Single parenteral administration of methylergometrine in the delivery room is apparently unproblematic for the breastfed infant, and may be used if it is really indicated. Postpartum oral treatment with methylergometrine over several days, or even weeks, is rarely indicated in modern obstetrics. It should be considered that this agent counteracts the natural uterine involution, which normally occurs during breastfeeding via prolactin secretion. Oxytocin, which promotes the milk ejection reflex, is preferable as a medical support for uterine involution. If, however, there are sound grounds to use methylergometrine for a protracted time, there is no need for breastfeeding to be limited.

Herpes zoster shingles chickenpox

Varicella zoster virus (VZV) has not been cultured from the milk with either herpes zoster or chickenpox (Frederick 1986), but VZV-DNA has been identified in breast milk (Yoshida 1992). One case of suspected transfer of VZV to an infant via breastfeeding has been reported, but the virus may have been transmitted by droplet or exposure to the rash. The overwhelming majority of HIV-positive children arc infected during the birth. Postpartum infection via breastfeeding has also been described. The virus has been delected in the mother's milk, especially among women with mastitis and infected infants (Pillay 2000. Semba 1999). On the other hand, the protective effect of substances in the mother's milk, such as maternal anti-HIV antibodies, lactoferrin, and secretory leukocyte protease inhibitors on a vertical transmission, has been discussed for a long time (Becquart 2000, van de Perre 1999). A South African study of 549 HIV-1 infected women showed that babies who were exclusively...

Dihydroergotamine and other antihypotensives

The use of dihydroergotamine during breastfeeding is considered safe. However, non-drug measures (sports, the use of cold water and brushes, moderate coffee consumption) should be the first choice for the treatment of hypotonia. Etilefrine and norfenefrine, as well as amezinium, gepefrin, midodrin, and pholedrin, should be avoided. However, accidental intake does not require interruption of breastfeeding.

Peristaltic stimulators

Hansen (2005), in a randomized double-blind study, investigated more than 60 mothers of preterm newborns, who received either metoclopramid or placebo. There were no significant differences with respect to the amount of milk and duration of lactation period. Other reports observed its successful use in, for example, the context of lactation stimulation in a woman with agenesis of the uterus. Although her pregnancy was carried by another woman, she wanted to breastfeed her child. Therefore, she started with 3 x 10 mg metoclopramide from week 28 until delivery (of the host-mother), and stimulated the nipples with an electric milk pump. The effect of this method was confirmed by serum prolactin and estradiol measures. She was ultimately able to breastfeed her child until 3 months of age however formula was used as a supplement because of insufficient milk production (Biervliet 2001). Recommendation. Domperidone, metoclopramide, and cisapride may be used for appropriate indications. The...

Special Considerations in the Selection of an Antidepressant

Pregnant women and nursing mothers Clinicians must consider whether the potential benefits of treatment justify the potential risk to the fetus. The risks of untreated depression are well-described, and the risks of medication treatment during pregnancy and lactation are less well-known. In general, studies have not shown increases in fetal malformations from antidepressant exposure. Reports of withdrawal syndromes among neonates have led some experts to recommend tapering and discontinuing antidepressants 10 to 14 days before the mother's due date. Antidepressants are excreted in varying degrees in breast milk, so breastfeeding in antidepressant-treated women should be done with caution.

Preliminary Guidelines

Pregnancy and Breastfeeding You need to be careful about the use of psychiatric medications if you are pregnant or breastfeeding. If you are unsure whether or not you are pregnant it is important to get a pregnancy test prior to beginning any psychiatric medications. Neither pregnancy nor breastfeeding precludes medications, but they must be used with extra caution. This is discussed in more detail in chapter 4.

Efficacy of immunization in breastfed infants

Many myths have circulated regarding the efficacy of immunization of the infant during breastfeeding. Actually, the immunogenicity of some vaccines is increased by breastfeeding, but long-range enhancement of efficacy has not been studied. In any case the response to vaccines while breastfeeding is not diminished, and the usual vaccination schedules should be followed. Hepatitis A vaccine is available in two preparations which are prepared from cell culture-adapted hepatitis A virus which has in turn been cultured in human fibroblasts and inactivated. It has not been studied in breastfeeding or in children under 2 years of age.

Insulin and oral antidiabetics

Recommendation, insulin and metformin are not problems during breastfeeding. Glibenclamide may also be taken however, the infant should be observed for symptoms of hypoglycemia after the start of therapy. Other oral antidiabetic should not be taken, but single doses do not require any limitation of breastfeeding.

The Editor

Karch served as a consultant to the Crown and helped prepare the cases against serial murderer Dr. Harold Shipman, who was subsequently convicted of murdering 248 of his patients. He has testified on drug abuse-related matters in courts around the world. He has a special interest in cases of alleged euthanasia, and in episodes where mothers are accused of murdering their children by the transference of drugs, either in utero or by breast feeding.

Duration

- Pregnancy and breast-feeding no contra-indication. The child may develop withdrawal symptoms, respiratory depression and drowsiness when the mother receives morphine at the end of the 3rd trimester and during breast-feeding. In these situations, administer with caution, for a short period, at the lowest effective dose, and monitor the child.

The Medications

Precautions are issues you should be aware of before you start any drug. Liver disease can impair the metabolism of any drug, and kidney disease can impair its excretion. Use extra caution with dosing if you have any impairment of your liver or kidney to avoid pronounced or prolonged effect. There are no studies establishing the safety of any drug during pregnancy or breastfeeding. Specific birth defects associated with a particular drug will be noted, but the absence of any specific defect doesn't mean that the drug is safe merely that nothing harmful has been linked to the drug. Almost all drugs are passed in the breast milk, so you should refrain from breastfeeding if you take any drug until you discuss it with your pediatrician and psychiatrist. Always notify your physician if you are pregnant, are considering pregnancy, or are breastfeeding. Use extra caution if you are over sixty-five, as you may be more sensitive than younger people to the effects of medication.

Addicted to love

There is some correlative evidence though, and it is worth considering. Oxytocin levels spike in women with orgasm and vasopressin levels spike in men when they ejaculate. Also, nipple stimulation from breast feeding causes oxytocin levels to raise in women, further supporting a role in pair bonding between mother and child. In a series of experiments where people viewed images of people they were sexually involved with, brain imaging techniques revealed that the same regions of the brain involved in cocaine addiction became more active. These regions have been shown to have a high concentration of oxytocin or vasopressin, or their receptor proteins. And, when men ejaculate, the region of the brain that lights up is the same region that is activated during a heroin rush. It kind of makes you want to try heroin. The point is that pair bonding likely reflects a similar mechanism to addiction and that the cues we use can vary and be enhanced by sexual...

Opiates

Severe withdrawal symptoms beginning, for the most part, within 24-72 hours postpartum, such as respiratory distress, hyperirri-tability, tremor, diarrhea, vomiting, disturbances in the sleep-wake rhythm, and, to some extent, therapy-resistant seizures, can quickly lead to death if they arc not treated (Boobis 1986). In 10 of the children, the occurrence of seizures and other withdrawal symptoms are delayed up to 10-36 days after birth. The risk of life-threatening withdrawal symptoms is particularly high when the mother's dependency is unknown and careful monitoring and phenobarbital prophylaxis are not started in time. Whether or not exclusive breastfeeding from birth onwards can minimize the withdrawal symptoms by passing opiates to the infant via the milk and should therefore be recommended is controversial - particularly if it does not involve controlled methadone withdrawal in the mother without further additional drug abuse, see also Chapter 4.16.

Paracetamol

Undesirable effects have been reported following breastfeeding (survey in Bar-Oz 2003, Bennett 1996). No side effects were observed among 43 breastfed infants of mothers treated with paracetamol (Ito 1993). Since metabolism and renal excretion are not fully developed in the newborn, accumulation cannot be ruled out in the case of long-term treatment (Notarianni 1987). Recommendation. Apart from Ibuprofen, paracetamol belongs to the group of analgesics of choice during breastfeeding.

Other antirheumatics

Passage into the mother's milk and tolerability during breastfeeding have not been studied sufficiently to assess risk. A case report describes two healthy babies who were breastfed for 3 months during maternal penicillamine therapy for Wilson's disease (Mcssner 1998). Recommendation. Among the basic antirheumatics, sulfasalazine and glucocorticoids and, in some instances, hydroxychloroquine are acceptable during breastfeeding. The American Academy of Pediatrics considers taking gold preparations while breastfeeding to be acceptable. This should be looked at critically because of the above pharmacokinetic data. Single doses of the other medications do not require any limitation of breastfeeding.

Local anesthetics

For normal use (dental treatment or minor surgery), local anesthesia may also be used during breastfeeding. This also applies to combinations with adrenaline. Prilocaine should be avoided, but if it is used accidentally there is no need to interrupt breastfeeding.

Gout therapy

Probenecid is the drug of choice for interval treatment of gout during breastfeeding. Allopurinol should be avoided whenever possible. Ibuprofen is the drug of choice with gout attacks. Phenylbutazone and colchicine should not be taken. However, Individual doses are not grounds for limiting breastfeeding. Whether women on a maintenance therapy with colchicine for FMF should breastfeed has to be decided upon Individually.

Antacids

Antacids and ulcer therapeutics of choice during breastfeeding are the newer aluminum combinations, such as magaldrate and sucralfate as well as aluminum-free antacids. Older aluminum and magnesium combinations are also acceptable. When higher doses are taken over

Nitrous Oxide

Fertility is lower in female rats exposed to nitrous oxide than in rats having no exposure. Lower fertility has also been observed among female health care workers with occupational exposure to the gas, and reduced fertility is also reported for males. Offspring of male mice exposed to nitrous oxide have weighed less than normal and have not matured as fast as normal. Birth defects resulted from an experiment exposing pregnant rats to the gas for 24 hours. When given to pregnant women during childbirth the drug builds up in the fetal blood and brain one authority recommends administering oxygen to any newborn whose mother received nitrous oxide while giving birth. As the twenty-first century began researchers reported that the gas might cause permanent fetal and newborn brain damage, a finding in contrast to previous understanding of the drug. Occupational exposure to nitrous oxide is associated with smaller infants and lower birth weight and may increase likelihood of...

Quinolones

Quinolones should not be used during breastfeeding. As a rule, a standard antibiotic with a lower potential for risk can easily be substituted for them. When a complicated infection (for example, of the urinary tract, or a Pseudomonas infection) really requires a quinolone, whenever possible ciprofloxacin should be preferred and breastfeeding continued.

Tuberculostatics

Tuberculostatics of choice during breastfeeding are isoniazid (in combination with 0.5-1 mg vitamin B6 prophylaxis per day for the infant), rifampicin, and pyrazinamide. Ethambutol is also acceptable. Streptomycin is a second-choice drug. If possible, it should not be used in the newborn period. Protionamide should be avoided.

Malarial drugs

M P quotients of between 2 and 6 have been calculated for chloro-quine. Following oral administration of 600 mg chloroquine base to breastfeeding mothers, peak values of 4.4mg l of milk were measured (Ogunbona 1987). However, the main metabolite, desmethyl-chloroquine, also needs to be considered. With the very long half-life, continuing high plasma milk levels can be expected despite weekly intake of malaria prophylaxis. Assuming a weekly (prophylactic) dosage of 500 mg chloroquine phosphate (which equals approximately a 300-mg chloroquine base), a weight-related dosage of just 1 mg kg daily is calculated for the mother. According to two studies (Ette 1987, Edstein 1986), an average of between 1 and 12 ) of the maternal weight-related daily dosage is transmitted by the milk to the baby. With the prophylactic dosage common here, that would be up to 0.1 mg kg daily. Chloroquine can be detected in the infant's urine (Witte 1990). However, despite the not insignificant transfer into the...

Antihelminthics

Pyrviniumembonate, mebendazole, niclosamide, and pyrantel are, practically speaking, not absorbed, and seem to be tolerated during breastfeeding. This probably also applies to the echinococcus drug albendazole. Praziquantel appears in mother's milk in limited amounts (Putter 1979). Recommendation. Pyrviniumembonate or mebendazole should be used to treat oxyuris (pin worms) niclosamide for band worms and mebendazole for other worm infestations. With echinococcus, albendazole may also be used. Ivermectin may be used if necessary. If there is really no alternative to praziquantel, this may also be prescribed without any limitation of breastfeeding.

Polio vaccine

Cases, it has been reported in infants Mertens 1983, Heyne 1977), When immunization is urgent for the mother, the killed virus vaccine can be given to her intramuscularly. In the immunized mother, polio antibodies are present in the milk at a level comparable to the mother's plasma levels. High concentrations of anti-polio virus antibody in the milk could theoretically interfere with the response of the breastfeeding infant to immunization, but no such outcome has ever been reported.

Rubella vaccine

Rubella vaccine is a live virus of the RA 27 3 strain grown in human diploid cell cultures and attenuated. It can be given in a combination vaccine (MMR). The early postpartum period, when risk of pregnancy is lowest, is the best time to be immunized. The risk to the breastfeeding infant is minimal with the recent techniques for vaccine preparation. The original preparations in the 1970s were associated with several cases of rubella. While the virus may appear in the milk, as reported in several studies (Losonsky 1982, Isacson 1971), symptoms in these infants were rare (Landes 1980).

Immunoglobulins

Immunoglobulins are in general very large molecules and do no pass into milk. In addition, infants are given immunoglobulii directly. Immunoglobulins contain passive protective antibodie and are not contraindicated for newborns, and would not be con traindicated for a breastfeeding mother. Immunoglobulin is used with specific immunoglobulins in higl titer, such as immunoglobulin hepatitis B (Hepatitis B Imniuni Globulin) (HBIG), which is used when there is known exposure t< hepatitis B. If the mother is hepatitis-positive, the recommende regime is to give the newborn immunoglobulin within 12 hours o birth, plus the first dose of hepatitis B vaccine. If a mother i exposed to hepatitis B while breastfeeding, HBIG would not put thi child at any risk via the breast milk. If the child required HBIG a the same time, it would be necessary to medicatc the child dircctlj

Research Subjects

THC is concentrated in and secreted in human breast milk and absorbed by the nursing infant. Thus, it is not appropriate to include nursing women in cannabis-administration studies. Because of the health advantages to the infant of breast feeding over bottle feeding, care should be taken to avoid research participation becoming an incentive for the mother to stop nursing. This can be done by eliciting nursing status early in the screening process, before potential subjects are aware of the exclusion of nursing women.

Preceptor blockers

The following i-receptor blockers are preferred meto-prolol, Oxprenolol, propranolol (mostly used for tachycardial arrhythmia), timolol (as eye drops), and labetalol. If another d-receptor blocker has been taken, there is no need to limit the breastfeeding, but the medication should be changed.

Hydralazine

With 150mg daily of hydralazine, a maximum of 130 ig l was measured in the milk - which is 20(ig kg per day or 1 of the therapeutic dosage for an infant (Liedholm 1982). Following parenteral administration of 10-40 mg, an average of 47 g 1, including the hydrazone metabolites, was measured in the mother's milk. The M P ratio is 0.5. Up to 108ng I was found in the plasma of breastfed infants (Lamont 1986). By comparison, the plasma concentration in an infant being treated with 2mg kg was given as 1700 ng 1. No toxic symptoms have been observed while breastfeeding. Dihydralazine can be evaluated similarly. Recommendation. Hydralazine and dihydralazine are among the antihypertensives of choice during breastfeeding.

ACE inhibitors

Following the use of ACE inhibitors in late pregnancy, kidney function disturbances as extreme as anuria requiring dialysis were seen in the newborn (Schubiger 1988), but this was not seen during breastfeeding. Thus, the American Academy of Pediatrics considers the use of those ACE inhibitors that have been tested for a long time to be acccptablc during breastfeeding. Recommendation. Those ACE inhibitors that have been in long use, such as captopril, enalapril, and benazepril, can be used during breastfeeding when the antihypertensives of first choice are not effective or not indicated. As a safety measure, attention should be paid to edema and a possible increase in the infant's weight as indicators for disturbed kidney function. Accidental prescribing of another ACE inhibitor does not require limiting breastfeeding, but the therapy should be changed.

Digitalis

Digoxin, acetyldigoxin, and methyldigoxin are no cause for concern during breastfeeding. With daily administration of 1800 mg of quinidine, a maximum of 9 mg l was measured in the milk. For a fully breastfed infant, this was up to 1.3mg kg daily, or about 4 of the maternal weight-related dosage. The M P ratio is 0.9. Despite possible accumulation due to the infant's delayed metabolization, the American Academy of Pediatrics sees no cause for concern in using it during breastfeeding. There are no case reports on symptoms in breastfed children. Flecainide was found in the milk of several test subjects in long-term treatment with 2xl00mg daily, at concentrations of 0.27-1.53 (ig ml (McQuinn 1990, Wagner 1990). Based on the highest value, an infant could get just about 7 of the maternal weight-related dosage. The American Academy of Pediatrics does not have any objection to the use of this drug (which is also used therapeutically in newborns) in breastfeeding. Adenosine...

Other anticoagulants

Low-dose acetylsalicylic acid (80-300 mg daily) is widely used to inhibit thrombocyte aggregation, and is wcil-toleratcd during breastfeeding. There is a case study on lepirudine in which a breastfeeding mother who could not tolerate heparin received 50 mg of this hirudin derivative subcutaneously, twice a day, for 3 months. The maternal plasma showed 0.73 mg 1, a therapeutic concentration, and virtually no hirudin was detected in the milk < 0.1 mg 1). The breastfed child had no symptoms (Lindhoff-Last 2000). There is insufficient experience for argatroban, clopidogrel, and ticlopidine during breastfeeding. Recommendation. Breastfeeding may continue after using fibrinolytics. Lindhoff-Last E, Willeke A. Thalhammer C et al. Hirudin treatment in a breastfeeding woman. Lancet 2000 355 467. von Kries R. N cker D, Schmitz-Kummer E et al. Transfer of phenprocoumon in breast milk. Is oral anticoagulation with phenprocoumon a contraindication for breastfeeding in German , Monatsschr...

Antimanic drugs

Anticonvulsants are also used prophylactically against manic-depressive episodes, especially when there are contraindications for lithium. See Chapter 4.8 regarding their use during breastfeeding. Recommendation. Breastfeeding may be permitted when the baby is carefully observed (muscle tone, tremor, involuntary movements, cyanosis, dehydration) and the maternal lithium dosage is kept as low as possible. In cases of symptoms potentially associated with the drug therapy, a pediatrician and a teratology information center should be contacted to decide individually upon measuring drug values in the infant's serum, supplementary formula feeding, weaning, and or changing therapy. As with all psychoactive drugs, there is insufficient experience on the long-term effects on breastfed children as a result of ongoing therapy to their mothers.

Other anxiolytics

For buspirone, hydroxyzine, and kavain, there are either no or insufficient data on their use during breastfeeding. Like the other older antihistamines, hydroxyzine can lead to sedation or irritability in the infant. The half-life of zopiclone is about 5 hours. In a study in which 12 breastfeeding women received a single dose of 7.5 mg, levels of 80 ig l and 34ng l were found in the maternal serum and in the milk, respectively. A maximum of 4 of the maternal weight-related dosage was calculated for the infant (Mathcson 1990B). Another study involving three mothers showed similar results (Gaillot 1983). There are either no or insufficient data on the use of chloral hydrate, doxylamine, and eszopiclone, the S-enantiomere of zopiclone during breastfeeding. There is no indication that valerian products are not well-tolerated by the breastfeeding baby. Recommendation. Valerian poses no problem during breastfeeding however, if it is taken repeatedly, then preparations without alcohol or...

Immunomodulating and

At one time immunomodulating and antineoplastic agents were automatically considered a contraindication to breastfeeding, because any amount of antimetabolic drug was contraindicated in a newborn or young infant. Some of the newer compounds have relatively short half-lives and thus much shorter total clearance times (usually calculated as 5 x half-life). It is possible, therefore, for a woman determined to breastfeed her infant to pump and discard her milk right after a dose of medication, continuing until it has totally cleared. She then resumes breastfeeding until she receives another dose 2 or 3 weeks later.

Corticosteroids

Corticosteroids are of practical significance during breastfeeding. Those that are used therapeutically include the non-fluorinated prednisone, prednisolone, and methylprednisolone, as well as deflazacort, hydrocortisone and prednylidene and the fluoridated substances amci nonide, beclomethasone, betamethasone, budesonide, cloprednol, dexamethasone, flunisolide, flumetasone, fluocortolone, fluticasone, mometasone, and triamcinolone. Some preparations arc used exclusively as inhalants for treating obstructive respiratory illnesses. Other authors have reported proportional or even lower transfer amounts with a lower daily dosage of 10-80 mg (survey by Bennett 1996, Greenberger 1993). All in all, an average of 1-2 of the maternal weight-related dosage can be expected for the infant. In the case of the 1-g dose described above, the infant received 0.2 mg of prednisolone per kg bodyweight with the first breastfeed an hour after the injection. Over 24 hours, it was 0.32mg kg. Even this...

Prostaglandins

Prostaglandins are, for the most part, used in obstetrics for priming and inducing labor. After birth, other pharmaceuticals are used for uterine involution so that therapy during breastfeeding for obstetrical indications is not common. Latanoprost is administered as eye drops for glaucoma. Recommendation. Prostaglandins should only be used for compelling treatment indications during breastfeeding. If severe glaucoma requires local treatment with latanoprost, breastfeeding can continue provided there is careful observation of the baby. Single doses of other prostaglandins, such as misoprostol for uterine atony, do not require any limitation of breastfeeding.

Biphosphonates

Even though a direct harmful effect on the breastfed child would not be expected, these medications should, if possible, not be used during breastfeeding. If alendronate is required during lactation, the infant should not be breastfed for 2 hours after dosing. The present forms of drug require dosing only once a week. If etidronate is necessary during lactation, breastfeeding should be delayed for more than 2 hours to avoid the peak plasma time. Pamidronate is poorly absorbed orally, so it is not considered to be a problem for the breastfed infant.

Infections

There are very few situations where a mother who is breastfeeding and develops an infection puts her infant at risk because the infection might be transmitted through the milk. Vertical transmission after birth mainly occurs via close contact between mother and child. Pathogens discussed in context with breast milk transmission are HIV, human cytomegaly virus (HCMV), and - limited to tropical regions - Human T cell lymphotropic virus (HTLV), with the potential for leukemia, myelopathies, and neurological diseases (Biggar 2006, Lawrence 2004). The following sections discuss the most important infections. The issue of anti-infectious drug therapies has been covered in Chapter 4.4.

Simple infections

The most common questions arise because the mother has developed a fever of unknown origin in the immediate postpartum period. The most likely is a urinary tract infection, an upper respiratory infection or a wound infection. Modest engorgement also may cause a fever. Breastfeeding docs not need to be interrupted while the work-up is completed. Treatment may be initiated or found unnecessary. An infection with rt-hemolytic strep requires aggressive therapy for both mother and infant, interrupting breastfeeding until the mother has received 24 hours of antibiotics. Illness in the infant requires neither interruption of breastfeeding, nor separation of mother and infant. For viral infections, breastfeeding is not interrupted and can be therapeutic, as mother provides her antibodies through the milk to her infant.

Mastitis

Mastitis is not a contraindication to breastfeeding in fact, it is important to continue to empty the breast on the usual schedule. Even when an abscess has to be surgically drained, breastfeeding should continue unless the incision for drainage is on the areola. An undiagnosed abscess that ruptures spontaneously into a duct would require interruption of breastfeeding on that breast, and the breast would require routine pumping on schedule to hasten the healing. Direct breastfeeding on that breast should resume as soon as drainage stops and antibiotic therapy has been in place at least 24 hours. Most common causes are staphylococcus and E. coli. If streptococcus is suspected by culture or because mastitis is bilateral, the infant should also be treated vigorously. The diagnosis is made when a tender, warm, red swollen area appears on the breast, usually in a wedge shape, and the mother has a temperature and flu-like symptoms. In contrast, plugged ducts arc not red and warm, and the...

Hepatitis B

Regardless of how the infant will be fed, every child born to a hepatitis-B-positive mother should receive hepatitis B-immunoglob-ulin (HBIG) within 12 hours of birth. The infant should then also receive the first of three doses of hepatitis B vaccine. As soon as the HBIG has been given, the infant may begin breastfeeding (American Academy 2005, Lawrence 2005).

Hepatitis E

A study covering 93 pregnant women with hepatitis E (36 anti-It EV positive and 57 HEV-RNA positive) infection was confirmed in a colostrum specimen. However, parameters were significantly lower compared to maternal blood (Chibber 2004). Some of the infants of mothers with acute infection also developed liver symptoms. There was no indication that transmission occurred via breast milk. The authors concluded that breast feeding is probably safe, but stress the need to confirm their results by other studies, and the possibility that close contact between mother and child may facilitate transmission. Recommendation. There is no evidence yet that breastfeeding should be prohibited in cases of hepatitis E. However, experience is insufficient definitely to exclude any risk.

New Mothers Guide to Breast Feeding

New Mothers Guide to Breast Feeding

For many years, scientists have been playing out the ingredients that make breast milk the perfect food for babies. They've discovered to day over 200 close compounds to fight infection, help the immune system mature, aid in digestion, and support brain growth - nature made properties that science simply cannot copy. The important long term benefits of breast feeding include reduced risk of asthma, allergies, obesity, and some forms of childhood cancer. The more that scientists continue to learn, the better breast milk looks.

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