Codeine has a half-life of 3-4 hours; less than 25% is bound to the plasma protein, and the M/P ratio is 2. Bradycardia was observed in a 1-week-old infant after a single maternal dose of 30 mg codeine (Smith 1982). in another case, following a 60-mg single maternal dose, a maximum of 455 ug/I in milk was measured (Findlay 1981). Mathematically, for the infant this means a maximum of 7% of the weight-related maternal dosage. Here, and also in other studies, breastfed infants showed no symptoms when the daily maternal dosage remained under 240 mg, as recommended by some authors (Mcny 1993). As an antitussive, and for sporadic analgesic use, this amount is not reached by any means. Recently, fatal consequences were reported in a newborn whose mother was prescribed 60 mg codeine twice daily, with 1000 mg paracetamol, for episiotomy pain following birth. She reduced the dosage by half from day 2 becausc she experienced somnolence and constipation. The full-term healthy male infant showed intermittent periods of difficulty with breastfeeding and lethargy starting on day 7. On day 12, he had gray skin and his milk intake had fallen. He was found dead on day 13. The postmortem blood concentration of morphine (the active metabolite of codeine) was 70 ng/ml, while a milk sample from day 10 showed 87 ng/ml. A familial polymorphism of the enzyme CYP2D6 was diagnosed, resulting in extensive or even ultra-rapid metabolization of codeine to morphine in the child and his mother, respectively (Koren 2006).
In the case of a codeine-dependent mother (300 mg daily), 1 mg/1 of codeine was found in the urine of her neurologically remarkable infant. In the case of a heroin-dependent mother who took 625 mg of codeine daily as replacement, 1.5 mg dihydrocodeine/1 was measured in the serum of her cyanotic and apneic child (author's observations).
There are no case reports on the use of dextromethorphan during breastfeeding. The substance is a d-isomer of the codeine analog levorphanol. It has no analgesic properties. Sedative action and the potential for depcndcncy arc said to be tower than with codeine.
The administration of 150 mg of noscapin led to a concentration of a maximum of 83|ig/l of milk (Olsson 1986). This represents 12.5ng/kg daily for the infant, which is 0.5% of the maternal weight-related dosage. Following experimental results, mutagenic properties were attributed to noscapin.
In connection with pentoxyverin, a child with apnea episodes lasting up to 15 seconds was described (Stier 1998). The mother had taken 90 mg daily. The levels measured in the infant's serum were said to be higher than those in the maternal serum. The M/P ratio was given as 10; the half-life for the child was 5 days. Mathematically, 660 ml of mother's milk (the daily quantity) had only 93 ng pentoxyverin. Apnea, sometimes accompanied by cyanosis, had already been observed earlier in young infants when pentoxyverin had been administered therapeutically (Miihlendahl 1996).
There is no experience with benproperine, clobutinol, dropropizine, eprazinone, isoaminil, menadiol, and pipacetate in breast milk in lactating women.
Recommendation. A cough suppressant should only be considered in the case of ongoing unproductive and severe coughing. Before considering this, inhalation therapy, abundant fluid, and the administration of expectorants should be tried.
Single doses of dextromethorphan and codeine are allowed during breastfeeding. Repeated dosages require close observation for somnolence. Pentoxyverin is contraindicated. Benproperine, clobutinol, dropropizine, eprazinone, isoaminil, menadiol, noscapin, and pipacetate should not be used. However, the accidental administration of single doses of these medications requires only a change of therapy and no limitation on breastfeeding.
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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.