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Introduction
Over the
years, far too many women have been wrongly told they had to stop
breastfeeding. The decision about continuing breastfeeding when the mother takes
a drug, for example, is far more involved than whether the baby will get any in
the milk. It also involves taking into consideration the risks of not
breastfeeding, for the mother, the baby and the family, as well as society.
And there are plenty of risks in not breastfeeding, so the question essentially
boils down to: Does the addition of a small amount of medication to the
mother’s milk make breastfeeding more hazardous than formula feeding? The
answer is almost always: Almost never. Breastfeeding with a little
drug in the milk is almost always safer. In other words, being careful means
continuing breastfeeding, not stopping.
Remember
that stopping breastfeeding for a week may result in permanent weaning since the
baby may then not take the breast again. On the other hand, it should be taken
into consideration that some babies may refuse to take the bottle completely, so
that the advice to stop is not only wrong, but often impractical as well. On top
of that it is easy to advise the mother to pump her milk while the baby is not
breastfeeding, but this is not always easy in practice and the mother may end up
painfully engorged.
Breastfeeding and Maternal Medication
Most drugs appear in the milk, but usually only in tiny amounts. Although a very
few drugs may still cause problems for infants even in tiny doses, this is not
the case for the vast majority. Nursing mothers who are told they must stop
breastfeeding because of a certain drug should ask the physician to make sure of
this by checking with reliable sources and/or prescribing an alternative safe
medication. In this day and age, it is rarely a problem to find a safe
alternative. If the prescribing physician is not flexible, the mother should
seek another opinion, but not stop breastfeeding.
Why do
most drugs appear in the milk in only small amounts? Because what gets into the
milk depends on the concentration in the mother’s blood and the concentration in
the mother’s blood is often measured in micro- or even nano-grams per millilitre
(millionths or billionths of a gram), whereas the mother takes the drug in
milligrams (thousandths of grams) or even grams. Furthermore, not all the drug
in the mother’s blood can get into the milk. Only the drug that is not attached
to protein in the mother’s blood can get into the milk. Many drugs are almost
completely attached to protein in the mother’s blood. Thus, the baby is not
getting amounts of drug similar to the mother’s intake, but almost always,
much much less on a weight basis. For example, in one study with paroxetine (Paxil),
the baby got less than 0.3% of the drug for each kilogram of his weight than the
mother did (the mother got over 300 micrograms per kg per day, whereas the baby
got about 1 microgram per kg per day).
Most drugs are safe if:
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They are commonly prescribed for
infants. The amount the baby would get through the milk is much less
than he would get if given directly.
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They are considered safe in pregnancy.
This is not always true, since during the pregnancy, the mother’s body
is helping the baby’s get rid of drug. Thus it is theoretically possible
that toxic accumulation of the drug might occur during breastfeeding
when it wouldn’t during pregnancy (though this is probably rare).
However, if the concern is for the baby’s merely getting exposed
to a drug, say an antidepressant, then the baby is getting exposed to
much more drug at a more sensitive time during pregnancy than during
breastfeeding.
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They are not absorbed from the stomach
or intestines. These include many, but not all, drugs given by
injection. Examples are gentamicin (and other drugs in this family of
antibiotics), heparin, interferon, local anaesthetics, omperazole.
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They are not excreted into the milk.
Some drugs are just too big to get into the milk. Examples are heparin,
interferon, insulin,
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The
following are a few commonly used drugs considered safe during breastfeeding:
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Acetaminophen (Tylenol, Tempra),
alcohol (in reasonable amounts), aspirin (in usual doses, for short
periods). Most antiepileptic medications, most antihypertensive
medications, tetracycline, codeine, nonsteroidal antiinflammatory
medications (such as ibuprofin), prednisone, thyroxin, propylthiourocil (PTU),
warfarin, tricyclic antidepressants,
sertraline (Zoloft), paroxetine (Paxil), other antidepressants,
metronidazole (Flagyl), omperazole (Losec), Nix, Kwellada.
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Note:
Though generally safe, fluoxetine (Prozac) has a very long half life (stays in
the body for a long time). Thus, a baby born to a mother on this drug during the
pregnancy, will have large amounts in his body, and even the small amount added
during breastfeeding may result in significant accumulation and side effects.
These are rare, but have happened. There are two options that you might
consider:
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Stop the fluoxetine (Prozac) for the last
4 to 8 weeks of your pregnancy. In this way, you will eliminate the drug
from your body and so will the baby. Once the baby is born, he will be
free of drug and the small amounts in the milk will not usually cause
problems and you can restart the fluoxetine (Prozac).
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If it is not possible to stop
fluoxetine (Prozac) during your pregnancy, consider changing to another
drug which does not get into the milk in significant amounts once the
baby is born. Two good choices are sertraline (Zoloft) and paroxetine (Paxil).
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Medications applied to the skin, inhaled
(for example, drugs for asthma) or applied to the eyes or nose are
almost always safe for breastfeeding.
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Drugs for local or regional anesthesia are
not absorbed from the baby’s stomach and are safe. Drugs for general
anesthesia will get into the milk in only tiny amounts (like all drugs)
and are extremely unlikely to cause any effects on your baby. They
usually have very short half lives and are eliminated extremely rapidly
from your body. You can breastfeed as soon as you are awake and up to
it.
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Immunizations given to the mother do not
require her to stop breastfeeding. On the contrary, the immunization
will help the baby develop immunity to that immunization, if anything
gets into the milk. In fact, most of the time nothing does get into
the milk, except, possibly some of the live virus immunizations, such as
German Measles. And that’s good, not bad.
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X-rays and scans. Ordinary X-rays do not
require a mother to stop breastfeeding even when used with contrast
(example, intravenous pyelogram). The reason is that the material does
not get into the milk, and even if it did it would not be absorbed by
the baby. The same is true for CT scans and MRI scans. You do not
have to stop for even a second.
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What
about radioactive scans?
We do not
want babies to get radioactivity, but we rarely hesitate to do radioactive scans
on them. When a mother gets a lung scan, or lymphangiogram with radioactive
material, or a bone scan, it is usually done with technetium (though other
materials are possible). Technetium has a half life (the length of time it takes
for ½ of all the drug to leave the body) of 6 hours, which means that after 5
half lives it will be gone from the mother’s body. Thus, 30 hours after
injection all of it will be gone and the mother can nurse her baby without
concern about his getting radiation. But does all the radioactivity need be
gone? After 12 hours, 75% of the technetium is gone, and the concentration in
the milk very low. I think that after most radioactive scans, the mother can
continue breastfeeding, but if she and her physician are truly concerned,
waiting 2 half lives is enough, for a material such as technetium. Note that if
the mother is getting the scan during the first few days after the baby’s birth,
the baby will get much less because the baby gets much less milk during this
time. During this early period, I believe no interruption of breastfeeding is
necessary or desirable. Colostrum is desirable for the baby.
If you
decide that interruption of breastfeeding is the best course to follow, then
express milk for several days in advance (if you have advance warning about the
test). Only occasionally is a radioactive scan that urgent that it cannot be
delayed for a few days.
Thyroid scans are different. Radioactive iodine is concentrated in milk and
will be ingested by the baby and it will go to his thyroid where it will stay
for a long time. This is definitely of concern. So, the mother will have to stop
breastfeeding? No, because often the test does not need to be done.
Differentiating postpartum thyroiditis from Graves’ Disease (the most common
reason for doing the scan in nursing mothers) does not require a thyroid scan.
Get more information from your doctor or clinic. If a scan needs to be done, it
is possible to do a thyroid scan with technetium.
About The Author: Dr. Jack Newman is a Toronto
pediatrician who has practiced medicine since 1970. In 1984 he established the
first hospital based breastfeeding clinic in Canada, at the Hospital for Sick
Children in Toronto. He now holds breastfeeding clinics in several Toronto area
hospitals. Jack has been a consultant with UNICEF's Baby Friendly Hospital
Initiative and has spoken at conferences around the world. He is the father of
three children, all breastfed.
Dr. Newman is the author of
"The Ultimate Breastfeeding Book of Answers"
NOTE: The article above titled "Drugs
and Breastfeeding; You Should Continue Breastfeeding (1)" was written by Dr. Jack Newman and is the opinion of its author. "The New Parents Guide" does not guarantee the information to
be factual. Always use the guidance of your personal
doctor or your child's doctor over information you read on this site or elsewhere; your doctors know what is
best for you and your baby.
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