Booby Traps Series: What your OB should know about breastfeeding and medications

This is the fifth in a series of posts on Booby Traps™ during pregnancy, made possible by the generous support of Motherlove Herbal Company.

Today’s post is written by Alison Stuebe, MD, MSc.  Alison is an assistant professor of Maternal-Fetal Medicine and Maternal-Child Health at the University of North Carolina School of Medicine, where she maintains a web site for clinicians on breastfeeding management.  She is the author of a number of studies on breastfeeding and its relationship to breast cancer and heart disease.  She is  member of the board of the Academy of Breastfeeding Medicine and a regular contributor to the Breastfeeding Medicine Blog.

A major Booby Trap™ in doctor’s offices stems from a simple – and obvious — fact: The breast is not the same as the placenta.

If you’ve seen a placenta (or have even the vaguest notion of what one looks like), this is not surprising information. The placenta is the caterer for your baby’s nine months in the womb. It’s about the width of a dinner plate, purple, and covered with blood vessels that ultimately coalesce into the umbilical cord. In other words, if your breast looks like a placenta, you have a serious problem.

Nevertheless, when it comes to what medications are safe in breastfeeding, many health care providers think the placenta and the breast are interchangeable. Clinicians routinely tell mothers not to take certain drugs during breastfeeding because they cause problems during pregnancy. Conversely, drugs that are okay for pregnancy can cause problems for a nursing mom.

For example, ACE inhibitors are a type of drug commonly used to treat high blood pressure. During pregnancy, they can cause serious problems for the baby’s kidneys, and they are never given to expecting moms. But the drug enalapril, which is an ACE inhibitor, is considered “usually compatible with breastfeeding,” by the American Academy of Pediatrics. The reason is that while the placenta delivers this drug directly to the developing baby’s kidneys, the breast lets very little into milk – the estimated exposure to the baby is less than 0.2% of a therapeutic dose.

I did not learn this in medical school, however. I learned it when I was a resident and was talking to a laboring mom about her infant feeding plans. She told me, “I wanted to breastfeed, but I can’t because of my blood pressure medication.” My first thought was, “Of course, because you can’t take ACE inhibitors during pregnancy.” But I looked it up – and went back to tell this mom, now 7 centimeters dilated in active labor, that she could breastfeed after all. Needless to say, this was not an ideal time or place to change one’s infant feeding plans.

To make matters worse, many of the resources that physicians and pharmacists turn to for information drug safety in lactation are wrong. Monica Akus and Melissa Bartick looked at this issue in a paper published in 2007 . They looked up the safety recommendations for 14 drugs commonly prescribed for young women. Two resources stood out as high-quality references: Dr. Thomas Hale’s book, Medications and Mother’s Milk, and LactMed, the National Library of Medicine’s lactation safety database .  Both resources found that 12 of the 14 drugs Akus and Bartick reviewed were generally safe during breastfeeding. By contrast, Lexi-Comp and First DataBank, two resources commonly used by pharmacies, rated only 1 or 2 of the drugs as safe in breastfeeding.

So let’s think about this Booby Trap™: A provider writes a prescription for a drug that’s okay to use during breastfeeding, and you go to pick it up in your pharmacy. Based on this study, ¾ of the time, you’ll be told – incorrectly – that you need to wean or express and discard your milk, or risk endangering your baby.

There’s a more subtle distinction that’s also often lost on medical providers. If the data on a drug’s safety profile is even slightly ambiguous, the standard advice is to “play it safe” and formula feed the baby. In the eyes of many clinicians, formula is a-OK, whereas breast milk with the possibility of medication exposure is risky. Such an approach discounts the well-documented risks of formula feeding for both mother and infant, and doesn’t take into account the mother’s own preferences about which risk is more concerning to her and her family. In fact, the family needs to weigh the risks of medication exposure against the risks of not breastfeeding. There is no “play it safe” option.

The reverse problem can also occur, when providers incorrectly advise that there’s no down side to a medication during breastfeeding. For example, consider pseudoephedrine, a common component of over-the-counter cold medicine that is considered OK in pregnancy after the first trimester.  A 2003 study found that a single, 60 mg dose of pseudoephedrine cut a woman’s milk production over 24 hours by 25% — from an average of 26 to 21 ounces. Yet the OB textbook, “Drugs in Pregnancy and Lactation,” summarizes the data on pseudoephedrine as “Limited Human Data – Probably Compatible” with breastfeeding.

So what’s a mom to do? Hopefully, your provider is knowledgeable and will look up medications on LactMed, Dr. Hale’s Medications and Mother’s Milk, or call Dr. Hale’s new Infant Risk Center free information line before making a recommendation. But before you fill a prescription or take an over-the-counter medication, you may want to look it up yourself. You can call Dr. Hale’s Infant Risk Center, and you could also bring the printed-out information from LactMed to your provider (and to your baby’s provider) and gently educate them about where to find high-quality information on drug safety in lactation.

Meanwhile, I get to meet with all the third-year medical students at UNC during their Obstetrics rotation, and I am making sure they all learn that the breast and the placenta are not the same organ.

Have you received any bad medication advice from your physician or pharmacist?   If so, how did you handle it?  Success strategies are welcome!

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13 Comments | Last revised on 03/18/2011

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