AAP report updates use of medications during breast-feeding

The American Academy of Pediatrics (AAP) clinical report released this week provides guidance for physicians about the use of psychotropic drugs, substance abuse treatments, narcotics, galactagogues, herbal products, and vaccines in breast-feeding women and the potential effects on the infant.

AAP suggested that clinicians consult the LactMed database for the most up-to-date information on specific drugs for the lactating women.

Previously AAP stated that the effect of psychoactive drugs on the breast-feeding infant was “unknown but may be of concern.” However, in this report, low concentrations of many antianxiety drugs, antidepressants, and mood stabilizers have been found in human breast milk. The estimated relative infant doses were less than 2% of the weight-adjusted maternal dose, reported Hari Cheryl Sachs, MD, and the Committee on Drugs, published online August 26 in Pediatrics.

“However, the percentage of maternal doses that approach clinically significant levels (10% or more) have been reported for bupropion, diazepam, fluoxetine, citalopram, lithium, lamotrigine, and venlafaxine,” Sachs wrote.

In addition, approximately one third of these drugs have no data concerning the drug’s excretion in human breast milk, Sachs wrote.

“Mothers who desire to breastfeed their infant(s) while taking these agents should be counseled about the benefits as well as the potential risk that the infant may be exposed to clinically significant levels and that the long-term effects of this exposure are unknown,” the report stated.

Drugs for substance abuse

Alcohol and illicit drugs used by lactating women can be toxic for the breast-feeding infant. So women must abstain from these drugs with the help of psychosocial support. For opioid dependent-women who are undergoing treatment with methadone or buprenorphine, they may continue to breastfeed as the levels of these drugs excreted into human breast milk are low. However, caution is advised for buprenorphine because of the risk of abuse.

“Labeling for buprenorphine…states that use is not advised by lactating women, because animal lactation studies have shown decreased milk production and viability of the offspring,” Sachs noted.

Labeling for disulfiram and naltrexone warns against use in breast-feeding women, including the oral and injectable forms of naltrexone.

For women who are breast-feeding and need smoking cessation treatment, the report recommends nicotine gum or lozenges, which are short-acting products. Labeling of bupropion and varenicline labels advises against use in breast-feeding women.

Pain relief

Codeine should not be used by breast-feeding women because of the risk of high levels of its active metabolite, morphine. The authors suggest instead the use of butorphanol, morphine, or hydromorphone for short periods if needed.

“Regardless of the choice of therapy for both the mother and her nursing infant, the lowest dose and shortest duration of therapy should be prescribed,” Sachs wrote.

“Other narcotic agents, such as oxycodone, pentazocine, propoxyphene, and meperidine, are not recommended in the lactating mother,” the report stated.

Oxycodone exposure caused central nervous system depression in 20% of infants who were breastfeed. Pentazocine has produced respiratory depression and apnea in treated neonates and preterm infants. Infants exposed to propoxyphene have had apnea, bradycardia, cyanosis, and hypotonia. Meperidine has produced decreased alertness, thus affecting breast-feeding.

Ibuprofen and acetaminophen can be used by breast-feeding women as these are short-acting drugs.

Galactagogues

Galactagogues, which include dopamine antagonists and herbal treatments, are not recommended for the lactating woman and her infant. The report stated that these products have not been fully assessed for their safety for the breast-feeding infant. Mothers should consider reaching out to a lactation consultant and using non-pharmacologic approaches for improved human breast milk production.

Immunizations

Breast-feeding infants in most cases are not adversely affected from maternal immunization. Also, breast-feeding will not be a problem for infants who receive routine vaccines such as diphtheria and tetanus toxoids and acellular pertussis vaccine, inactivated poliovirus vaccine, and hepatitis B vaccine (HBV). In fact, breast-fed and formula-fed babies who receive the rotavirus vaccine have similar conversion rates, the report stated.

“Several vaccines…are recommended for the mother during the postpartum period to protect the infant as well as the mother. Other routine or catch-up vaccines, such as HPV, hepatitis A vaccine, and HBV, can be given to the lactating mother,” Sachs noted.

The only vaccines that should not be given to lactating mothers in nonemergency situations are smallpox and yellow-fever vaccines.