Medications and the Breastfeeding Mother
Janell E. Robisch
Lorton VA USA
From: NEW BEGINNINGS, Vol. 20 No. 6, November-December 2003, pp. 204
When Trish Kuper suffered a sudden hearing loss with a severe ear infection, the physician she saw in Oklahoma City, Oklahoma, USA, recommended she take the steroid drug prednisone for the next month.
He also recommended she wean her nine-month-old daughter. When she expressed her distress over the idea, the doctor, who was an ear, nose, and throat specialist, said she also had the option of pumping and discarding her milk for the time she was on the drug. "I told him that was an impossibility," she said.
As happened with Trish, breastfeeding mothers often are advised to wean by doctors or other health care providers. It's seldom necessary, according to Thomas Hale, PhD, who specializes in studying how much medication transfers into human milk. In his book, Medications and Mother's Milk, he writes:
Although interrupting breastfeeding may seem safest to the physician, it is not really necessary in most cases as the amount of drug transferred to milk is normally quite small. It is well known that most medications have few side effects in breastfeeding infants because the dose transferred via milk is almost always too low to be clinically relevant or it is poorly bioavailable to the infant.
In most cases, the mother need only talk to her doctor and consult some of the other available resources to explore her options and find a treatment that works for her and her baby and that does not require weaning. Most medications are compatible with breastfeeding. When they are not, an alternative medication or procedure is almost always available.
After her doctor recommended that she wean, Trish Kuper went home, prescription in hand, and phoned a friend who was a board certified lactation consultant. Her friend read her information from Thomas Hale's book, which lists specific information for hundreds of medications; her friend also advised her that the American Academy of Pediatrics (AAP) had approved the use of prednisone, the drug that she was prescribed, for nursing mothers.
When a breastfeeding mother has a health problem that requires medication, it can be a challenging time. Doctors commonly recommend that a mother wean her baby if she is taking an over-the-counter or prescription medication. Mothers usually want to continue breastfeeding and do not want to stop in order to take medication, especially for an illness that probably won't last long, such as a cold.
In an effort to avoid the oftentimes remote risk of a medication having an effect on a breastfeeding infant, mothers sometimes underestimate the risk to themselves of not seeking treatment and doctors sometimes discount the risks of weaning.
A mother's illness may affect not only her health and physical well-being, but also how effective she is at mothering her children, if only temporarily. And, since breastfeeding is more than just a feeding method, weaning a baby in order to take medication dramatically alters the way a mother can care for and comfort her child. According to the new edition of THE WOMANLY ART OF BREASTFEEDING, published by La Leche League International:
Abrupt weaning is traumatic for mother and baby. [The] mother may develop painfully engorged breasts, risking a breast infection and compounding the problems for which she was advised to take the medication in the first place. The mother/baby relationship is adversely affected by sudden weaning. Caring for the baby and keeping him content becomes difficult or impossible; the baby is often utterly inconsolable.
As stated in THE WOMANLY ART OF BREASTFEEDING, documented risks also exist for babies who are not breastfeed.
A physician who advises weaning just as a precaution may not be considering the risks associated with feeding a baby infant formula. Formula is not the nutritional equivalent of human milk. Babies who are formula-fed are at greater risk of illness and allergy.
There are many things a mother and her doctor must consider when choosing a course of treatment, including the necessity of the medication, the compatibility of the medication with breastfeeding, and the availability of alternative medications or treatments. The age and health of the baby also play a role in weighing a medication decision. Weaning should be considered only as the last option.
Is the Medication Necessary?
The first and most obvious question that a mother needs to ask herself and her doctor should be whether medication is really necessary. Some mothers, who have a mild illness such as a cold, may forego taking medication in an effort to "protect" their baby. At the same time, since most medications are compatible with breastfeeding, there is rarely a true need for mother to suffer.
As the American Academy of Pediatrics writes, "Most drugs likely to be prescribed to the nursing mother should have no effect on milk supply or infant well being."
If, after considering all the options, the mother and doctor decide that taking medication is necessary, together they can explore which medication would be most compatible with breastfeeding.
Deciding Which Drug Is Best
The drugs that are most compatible with breastfeeding are time-tested: they have been used by nursing mothers for a long time and have not posed significant risks. These medications are also the least toxic to babies, have the shortest half-lives (and are eliminated more quickly from the mother's body), and are given in the smallest effective dose for the shortest amount of time (see sidebar for other factors that affect the compatibility of medications with breastfeeding). They are also drugs that pass in relatively small amounts into the mother's milk and, thus, into her baby's system.
There are other important points that a breastfeeding mother and her doctor should consider. First, medications that are commonly given to babies are often good choices for the breastfeeding mother. Also, a drug that has been used and tested over a long period of time is likely to be better characterized with respect to breastfeeding than one that is fairly new. If a mother is prescribed a fairly new drug about which little is known, she may ask her doctor about an alternative medication that has been around longer and about which more is known.
The age and health of the baby also affect how cautious mothers need be about a medication. Premature infants and infants with heart defects are much more vulnerable to the effects of medication than are healthy, full-term infants. Fortunately, mothers are more likely to be prescribed drugs once babies are past the newborn period. Babies who receive food other than human milk will receive a lower dose of the medication and their higher body weight also helps them metabolize any trace amount of medication in their mother's milk more quickly.
Also, some medications may not cause problems in the infant but may affect breastfeeding by reducing the mother's milk supply, depressing the release of prolactin (the hormone that affects milk production), or inhibiting the mother's let-down.
When Told to Wean
In some instances, a doctor might recommend that a mother wean either while she is taking a medication or permanently. Many factors may influence the doctor's often unnecessary recommendation, including the baby's health and age. Other, more subjective influences may also be at play.
Some doctors rely on biased sources of information. Many doctors use the Physicians Desk Reference as a source of information on various medications and their effects on breastfeeding. The information in this publication and some other publications, including the medical inserts provided with prescriptions, is provided by pharmaceutical companies and is often overcautious because of company fears of possible litigation. These companies, in order to protect themselves from possible litigation, may state that the effects on breastfeeding or on the breastfeeding infant are unknown or that a mother should not nurse while taking the medication.
It is difficult for ethical reasons to do drug research on pregnant women and breastfeeding dyads, but frequently if that research has not been done, the Physicians Desk Reference will state that a medication is not compatible with breastfeeding. More objective publications include Thomas Hale's Medications and Mother's Milk and the AAP's policy statement "The Transfer of Drugs and Other Chemicals Into Human Milk," both of which list a great number of medications and provide information and known research on their safety and their possible effects on both nursing babies and lactation itself.
Hale's book analyzes how much medication could possibly be transferred into human milk by looking at things like the molecular size of the chemicals in the medication and testing the content of the milk of mothers who have taken certain medication. When a very small perecentage of a drug's dose transfers into milk, it is less likely to affect even a young infant.
When little or no information is available about a fairly new drug, the mother may want to ask the doctor if there is a suitable alternative about which there is more information. Because most medications are compatible with breastfeeding, a little research may be the simple answer to what seems like a complicated problem. A mother might also point out the health and emotional risks to her and her baby that could arise from premature weaning.
Suzie Mattern of Woodbridge, Virginia, USA, was told that she would have to wean her exclusively breastfed baby for 36 hours for an x-ray procedure to confirm the position and number of the kidney stones that she had developed."I anxiously explained to the doctor that my daughter was exclusively breastfed and I was unable to pump enough milk in the next two days before the procedure and that this was not a possibility."
After consulting with a La Leche League Leader about possible alternatives and again with the doctor's office, she discovered that there was, indeed, an alternative and safer procedure that would not require her to interrupt breastfeeding. Suzie's willingness to question her doctor's decision and to research the procedure and talk further with her doctor saved her and her baby from a possibly traumatic 36-hour weaning.
A mother, with the help of her doctor and her baby's doctor, might also decide to take a medication about which little is known but closely monitor her baby for untoward side effects. In this way, the mother's medical needs are met while she is still watching out for the well-being of her child.
Some doctors believe that a mother should not take any medication while she is nursing and that she should wean her baby if she wishes or needs to take it. In this instance, a mother may want to seek a second opinion.In any case, mothers should always try to communicate openly with their doctors, let them know that they are breastfeeding and wish to continue to do so, and express their wish to take a medication that would pose the least risk to the baby and that would not require weaning (see sidebar).
As Angela Herrera writes in her article, "A Mother With Lupus," which was published in New Beginnings, "Don't assume your doctor will not listen. Physicians just may not know very much about taking medications while nursing a baby." She also writes that her exploration to find a course of treatment for her lupus that was compatible with breastfeeding was "also an informative experience for my doctors. I found they were eager to know more about breastfeeding and drugs in human milk."
When Weaning Is Necessary
Unfortunately, there are some medications, including those that contain radioactive compounds, that pose a higher risk to the breastfeeding baby than weaning does. Once a mother has explored all of her options and all of the possible alternatives and has come up empty, temporary or permanent weaning might be necessary, although fortunately this is rarely the case.
If the mother wishes and is able to continue breastfeeding after discontinuing such a medication, she can contact her local La Leche League Leader for information on how to express her milk and keep up her supply while she taking the medication. Leaders can also provide information on how to ease the stresses of both temporary and permanent weaning.
In the case of medications and mother's milk, the best thing that a mother can do is arm herself with information with which she can approach her doctor and discuss her alternatives in an educated and effective manner. There are many sources of information available on specific drugs.
One mother weaned her first son after being prescribed several medications in turn when she was diagnosed with postpartum depression and sleep deprivation. However, when her second son was born, she was armed with much more information (and confidence):
I was determined to bond well with my baby and nurse him until he decided to wean . . . . I had difficulty with pain control after the cesarean, but understood that I needed to take the pain medications in order to relax so we could nurse well," Christy Murrell of Centreville, Virgina, USA, says. "I had read enough to know that very few medications are truly contraindicated with breastfeeding, and I chose to take the medications the doctor prescribed . . . . These medications seemed to have no effect on William.
Sources in the Community
LLL Leaders are a wonderful source of information and support. LLL Leaders are not medical professionals and do not give medical advice; however, they have access to some of the resources listed below and may be able to provide mothers with published information on the drug being considered. Leaders are available over the phone and online through LLL's Help Forms. Local Groups (and their Leaders) can be located through LLL's Web site at www.llli.org/WebIndex.html.
Sometimes, the opinion of another medical professional can be of great use. A pediatrician who specializes in the health of babies and children or a pharmacist may have more up-to-date information on the effects of medication on babies than the prescribing doctor, especially if the prescribing doctor does not generally see infants.
When making the decision whether or not to take medication while breastfeeding, a mother is justified in searching for information and questioning authority. After all, mother's milk is essential for the baby, and breastfeeding is important to both mother and baby. The mother should be able to take care of herself and her own needs while still providing her baby with the best possible start. Fortunately, in most cases, this is no problem.
There are many factors that affect the possible risks of maternal medication for the baby, including the relative infant dose (how much of the medication passes into the mother's milk through her bloodstream). Fortunately, this dose is usually very small. Other factors include:
an Open Dialogue and
A mother's relationship with her doctor will be enhanced when she can express her feelings and her goals to her doctor. A mother may very well find it a bit intimidating to be in conflict with her doctor or to challenge his knowledge. If you are not comfortable with a treatment or medication that your doctor has recommended, THE BREASTFEEDING ANSWER BOOK suggests using "tact, honesty, respect, knowledge, and patience." Some other tips that might help you prepare and converse with your doctor about medications include:
Mohrbacher, N. & Stock, J. THE BREASTFEEDING ANSWER BOOK. Schaumburg, Illinois: La Leche League International, 2003.
Hale, T. Medications and Mother's Milk, 2002. Amarillo, Texas: Pharmasoft, 2002.
Herrera, A. A mother with lupus. New Beginnings 2001; 17(5)167.
WHEN A NURSING MOTHER GETS SICK . Schaumburg, Illinois: La Leche League International, 1996; 4-5.
THE WOMANLY ART OF BREASTFEEDING. Schaumburg, Illinois: La Leche League International, 2003.
American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics 2001; 108(3)776-789.
Briggs, B., Freeman, R. & Yaffe, S. Drugs in Pregnancy and Lactation. Baltimore, Maryland: Lippincott, Williams & Wilkins, 1998.
Ito, S. Drug therapy for breastfeeding women. The New England Journal of Medicine 2000; 343(2).
Klasco, R. K., Ed. USP DI(r). Vol. I. Drug Information for the Healthcare Professional. Greenwood Village, Colorado: Micromedex, 2003.
Lawrence, R. and Lawrence, R. M. Breastfeeding: A Guide for the Medical Profession. St. Louis, Missouri: Mosby, 1999; 351-393.