Book Review
Medications and Mothers' Milk, 9th edition
by Thomas Hale, PhD
Pharmasoft Publishing; 1999
Reviewed by Kathy Koch
Great Mills, Maryland, USA
From: LEAVEN, Vol. 37 No. 2, April-May 2001, p. 37
The 9th edition of Medications
and Mothers' Milk by Dr. Thomas Hale is by far the most current
and complete reference on drugs and breastfeeding presently available.
It is easy to read, provides explanations of medical words, and is affordable.
Updated annually, this edition brings with it the addition of 50 new
drug entries and two new categories (lactation risk category and theoretic
infant dose) to assist in determining the possible effects on a nursing
infant of a drug taken by the child's mother.
As LLL Leaders we often receive
calls and questions about taking a specific medication or herbal remedy.
it is important to remember that we cannot tell a mother if it is safe
for the mother or her nursling for her to take any particular medication
while she is breastfeeding. Nor can we encourage her to wean her baby
while taking medication or suggest any alternate medications. (See LEADER'S
HANDBOOK, Revised 1998 p. 211.) These decisions rest with the mother
after consultation with her health care practitioner. While keeping
these limitations in mind, Leaders will find Medications and Mothers'
Milk 9th edition, a valuable addition to their personal breastfeeding
libraries.
As this book is written with
both the lay breastfeeding counselor and the medical professional in
mind, some things may be a bit difficult to understand for someone without
a background in pharmacology or medicine, but Dr. Hale provides comprehensive
definitions and explanations. With careful reading, LLL Leaders and
members will be able to understand the terms used. Being able to explain
these terms to mothers is another issue, and Leaders need to take care
when giving this information to mothers that they are not "interpreting"
the information in the book but rather are strictly providing the information
as it appears in the book.
This book also contains
listings of several factors that can influence the amount of drug secreted
into human milk. Lipid solubility, molecular weight, protein binding,
milk:plasma ratios, oral bioavailability, volume of distribution, and
half lives are particularly useful information. This allows the Leader
to provide the mother with several parameters on which to make her decision.
Dr. Hale defines and explains these terms, and then explains how the
clinician can apply these terms to helping situations.
A typical drug listing provides
trade and generic names. This is helpful as many drugs go by more than
one brand name and their inclusion makes this book useful for evaluation
of medications around the world. The index is also quite thorough, listing
many generic and brand names for a particular drug. The drug's typical
uses are also listed.
The section on the American
Academy of Pediatrics' (AAP) recommendations may be confusing for some
entries. Because Dr. Hale forms his conclusions from peer-reviewed medical
journal articles and unpublished studies, as well as the recommendations
of the AAP, in some cases his recommendations differ from those of the
AAP For example, Cimetidine (Tagamet) is listed as "approved by
the AAP for use in breastfeeding mothers." Dr. Hale writes, however,
that "other choices for breastfeeding mothers should preclude the
use of this drug. Short term use (days) would not be incompatible with
breastfeeding." Diltiazem HCl (Cardizem) is AAP-approved for use
in breastfeeding mothers, but again, Dr. Hale writes that "authors
recommend against using diltiazem in breastfeeding mothers."
In other cases, the drug
is not AAP-approved, yet Dr. Hale has fewer concerns. For the listing
on Metronidazole Vaginal Gel, the AAP classifies this drug as a "drug
whose effect on nursing infants is unknown but may be of concern."
Dr. Hale adds information from a study finding "plasma levels following
administration are exceedingly low" and "milk levels following
intravaginal use would probably be exceedingly low." Again, Lorazepam
is also listed by the AAP as a "drug whose effect on nursing infants
is unknown but may be of concern." Dr. Hale adds more specificity
by referring to a study in which "there were no untoward effects
noted in any of the infants," and concludes that "it would
appear from these studies that the amount of Lorazepam provided via
milk would be clinically insignificant under most conditions."
These differences in findings
make it especially important for the Leader to read all information
verbatim and allow the mother, in consultation with her health care
professional, to draw her own conclusion.
Similarly, many entries have
suggestions for alternate medication options. This is of concern because,
as LLL Leaders, we are not to suggest or recommend the use of any medication.
Were a Leader to read this, it could be construed as a recommendation
that another medication be prescribed. LLL Leaders should take care
when using this book to give the mother the exact citation of the book
so the recommendation is clearly that of Hale and not the Leader.
The two new categories for
this edition are Lactation Risk Category and theoretic infant
dose. The Lactation Risk Category was created by Dr. Hale
to assist in evaluation of medications during breastfeeding. It is similar
to the more familiar Food and Drug Administration Pregnancy Risk Category
and includes five categories: Ll-Safest, L2-Safer, L3-Moderately Safe,
L4-Hazardous, and L5-Contraindicated. Dr. Hale provides a more detailed
description of these categories in the book's introduction. Again, it
is important to remember that this category is Dr. Hale's opinion and
is not supported by any independent organization.
The theoretic infant dose
is an estimate of the maximum possible dose an infant would receive
via mother's milk. Dr. Hale calculated this number using information
provided in published literature about the medications. This number
is only provided for a very few entries in this edition and is intended
to be used in conjunction with other data for a particular medication,
not as the only determinant of a medication's appropriateness.
This is a useful and valuable
reference. As with all non-LLL sources, however, LLL Leaders should
use the information in Medications and Mothers' Milk, 9th edition,
judiciously and wisely, taking into consideration LLL recommendations
regarding questions about medications while breastfeeding.
Last updated Thursday, August 31, 2006 by njb.
Page last edited Sun Oct 14 09:31:28 UTC 2007.
